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Daily Practice

Prior Authorization Issues Form

Type of Comment:

Type of Comment (indicate if new or recurrent as applicable):

Type of Comment:


General Information:

 


Please Provide the Following Information (*Required):

 

Patient’s Health Plan Text:

 


Name of Patient’s Health Plan

 

NameROBMText:

 


Name of Radiation Oncology Benefit Manager

 

TreatmentModalityText:

 


Treatment Modality in question

Treatment Modality:










TypeofProblem:

 


Type of Problem

Problem Type:




IssueDiscription:

 


Please provide a brief description of your issue/experience with preauthorization procedures

 

ContactedROBMText:

 


Have you contacted the ROBM and/or health plan?

ContactedROBM:
IfYesText:

If yes, please provide details

ASTROHelpText:

 


How may ASTRO be of further assistance?

 

FurtherInfo:

Please contact the Health Policy Department with any further questions at 703-502-1550.