Acessa Insurance Support Program

Provider Registration

This form is for physician offices that are using the Acessa Insurance Support Program to register for the program. This form typically only needs to be filled out once by the provider office to register the office’s information. If you have any questions, you can contact the Acessa Insurance Support Team by email at acessa@priahealthcare.com or by phone at (860) 266-2538.

Provider Enrollment – Acessa
Practice Address
City
State/Province
Zip/Postal
Country
Additional Location Address (1)
City
State/Province
Zip/Postal
Country
Facility Address
City
State/Province
Zip/Postal
Country
Facility Address (2)
City
State/Province
Zip/Postal
Country
Time (EST)
:
Time (EST)
:

A confirmation email will be sent after submission.