PRA user registration form

Complete this short survey to register your team for access to our Provider Roster Application (PRA) tool. Accountable Care Networks (ACNs) ensure your organization has coverage for each applicable role.

The PRA tool is only for ACN staff. If you work at an individual practice, you won't be granted access to the tool.

1. First name: *This question is required.

2. Last name: *This question is required.

3. Email address:
We'll use your email address as your PRA username. It will also be where we'll send your PRA notifications. *This question is required. This question requires a valid email address.

4. List the ACNs you will need access to in the PRA tool:
ACN #1 *This question is required.

ACN #2

ACN #3

5. Do you need access to additional ACNs? *This question is required.

ACN #4

ACN #5

ACN #6

ACN #7

ACN #8

ACN #9

6. Which PRA role are you requesting? *This question is required.

7. Will you serve as the ACN(s) primary contact?
If yes, your email and phone number will be made available in the PRA tool. Other ACNs will use this information to communicate with your organization. *This question is required.

8. If yes, provide your phone number.

8. Additional comments: