Alafair VeraWrap Reimbursement Support Program New Office Enrollment Form REQUIRED: Click here to complete a BAA with your enrollment Provider Enrollment - Alafair Biosciences Enrollment Type Are you enrolling as: * Physician's office to submit Prior Authorizations and/or Pre-Service Appeals Facility to submit Post-service Claim Appeals Portal User Information User Contact Name * User Contact Name First First Last Last User Contact Email * User Contact Phone * Add Remove Practice Information Practice Name * Practice Address * Practice Address Practice Address Practice Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Practice Phone * Practice Fax * Practice NPI * Practice Tax ID * Physician Information Physician Name * Physician NPI * Physician Tax ID * Physician PTAN * Add Remove Facility Information Facility Name * Facility Address * Facility Address Facility Address Facility Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Facility Phone * Facility Fax * Facility NPI * Facility Tax ID * Add Remove Facility Physician Information Physician Name * Physician NPI * Physician Tax ID * Physician PTAN * Add Remove Alafair Biosciences Representative Name * Date: Onboarding Call Availability (Option 1) Date: Onboarding Call Availability (Option 2) Time EST (Option 1) 121234567891011 : 0030 AMPM Time EST (Option 2) 121234567891011 : 0030 AMPM If you are human, leave this field blank. Submit PROGRAM SUPPORT: MONDAY–FRIDAY 8:30AM–5:00PM EST PHONE: 860-266-1756 FAX: 860-733-0951 EMAIL: versawrapreimbursement@priahealthcare.com
