1.Contact information:

Surgeon name:

Surgeon specialty:

Location of practice (city, state):

Key contact/practice manager name:

Phone number:

E-mail address:

2.Name of private insurance company:

3.Type of health plan:

Health Maintenance Organization (HMO)

Participating Provider Option (PPO)

Point-of-Service (POS)

Health Savings Account (HSA)

Fee-for-Service (FFS)

Other (please specify)

4.Do you have a provider agreement with this insurer?

Yes

No

5.What type of issue are you experiencing with this insurer? Please select all that apply.

Lack of coverage

Prior authorization

Surprise billing

Network adequacy

Narrow networks

Tiering

Denied or returned claims

Other (please specify)

6.Please provide a complete description of this issue. If applicable, please include details about the type of services being performed and the CPT codes reported for such services.

7.Is this a recurring issue?

Yes

No

8.If yes, approximately how many times have you experienced this issue?