Prior Authorization and/ or Denial Reporting Form

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.)
5.In what country do you currently reside?(Required.)
6.Describe the issue with the RBM or payer.(Required.)
7.Please enter your email address or phone number (your preferred contact information).(Required.)