Carrier advocacy request

The society has developed this form for members to submit carrier information when denied reimbursement to the physician or the patient for specific interventional radiology treatments. To initiate societal comment letters, please complete the information below:

SIR membership number

First name *

Last name *

Email address *

Phone number

Denial information

Info

Please complete as many fields as possible.

Carrier

Denial reason

State

Alternative contact

text

Please provide an additional office contact who can answer questions regarding the denial.

Name

Attach copy of denial letter. *

Consent for storing submitted data *

Yes, I give permission to store and process my data