Prior Authorization and/ or Denial Reporting Form

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* 1. Which payer was the denial or prior authorization issue from?

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* 2. Which RBM (radiology benefits manager) was the denial or prior authorization issue from?

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* 3. What city do you reside in?

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* 4. What state do you reside in?

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* 5. In what country do you currently reside?

United States

Other (please specify)

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* 6. Describe the issue with the RBM or payer.

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* 7. Please enter your email address or phone number (your preferred contact information).