Alafair Biosciences

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:

Portal User Information

User Contact Name
User Contact Name
First
Last

Practice Information

Practice Address
Practice Address
City
State/Province
Zip/Postal

Physician Information

Facility Information

Facility Address
Facility Address
City
State/Province
Zip/Postal

Facility Physician Information

Time EST (Option 1)
Time EST (Option 2)

 

 

PROGRAM SUPPORT:

MONDAY–FRIDAY 8:30AM–5:00PM EST
PHONE: 860-266-1756  FAX: 860-733-0951
EMAIL: versawrapreimbursement@priahealthcare.com