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

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

*3.What city do you reside in?(Required.)

*4.What state do you reside in?(Required.)

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia (DC) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

*5.In what country do you currently reside?(Required.)

United States

Other (please specify)

*6.Describe the issue with the RBM or payer.(Required.)

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