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 [email protected] or by phone at (860) 266-2538.

Provider Enrollment - Acessa

Practice Name *

Practice Phone Number *

Practice Fax Number *

Practice Address *

Practice Address

City

State/Province

Zip/Postal

Country

Practice Tax ID *

Practice NPI *

Admin Contact Name (First and Last) *

Admin Contact Email *

Admin Contact Phone *

Acessa Sales Representative Name *

Physician Name (1) *

Physician NPI (1) *

Physician Tax ID (1) *

Physician PTAN (1)

Physician Name (2)

Physician NPI (2)

Physician Tax ID (2)

Physician PTAN (2)

Additional Location (1)

Additional Location Address (1)

City

State/Province

Zip/Postal

Country

Phone (1)

Tax ID (1)

NPI (1)

Facility Name *

Facility Address *

Facility Address

City

State/Province

Zip/Postal

Country

Facility Phone *

Facility Tax ID *

Facility NPI *

Facility Name (2)

Facility Address (2)

City

State/Province

Zip/Postal

Country

Facility Phone (2)

Facility Tax ID (2)

Facility NPI (2)

Date: Onboarding Call Availability (Option 1)

Time (EST)

Date: Onboarding Call Availability (Option 2)

Time (EST)

A confirmation email will be sent after submission.