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Practice Name

Contact email


Insurance Company *

Prior Authorization Vendor *

Procedure Requested

Patient indication *

Procedure Requested *

Did the requesting provider consult the AUC? *

If so, what was the level of AUC? *

What was the given reason for initial PA denial? (select as many as apply) *

After initial denial, what was the result of the peer to peer consultation? *

If test substitution was requested, what test was substituted? (select as many as apply) *

Select the type(s) of practice professionals handling this PA request (select as many as apply) *

How many minutes of practice (cv professionals and staff) time were required to complete the PA process? *

Did your patient have to delay and/or reschedule his/her test/procedure due to the PA process? *

Additional notes

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