Highridge Medical / Tether - PRIA Enrollment

Tether Patient Access Program

Provider Enrollment - Highridge Medical

User Contact Name

First

Last

User Contact Email *

User Contact Phone *

Practice Name *

Practice Phone Number *

Practice Fax Number *

Practice Address *

Practice Address

City

State/Province

Zip/Postal

Practice Tax ID Number *

Practice National Provider Identifier (NPI) *

Physician Name *

Physician Tax ID Number *

Physician National Provider Identifier (NPI) *

Provider Transaction Access Number (PTAN-Medicare) *

Facility Name *

Facility Address *

Facility Address

City

State/Province

Zip/Postal

Facility Phone *

Facility Tax ID Number *

Facility Provider Identifier (NPI) *

Tether Sales Representative Name *

Date: Onboarding Call Availability (Option 1)

Date: Onboarding Call Availability (Option 2)

Time EST (Option 1)

Time EST (Option 2)

PROGRAM SUPPORT:

MONDAY–FRIDAY 8:30AM–5:00PM EST
PHONE: 860-321-1356 FAX: 860-734-4827
EMAIL: TETHER@PRIAHEALTHCARE.COM