OOS Reimbursement Assistance Request

Complete the information below and submit your request.

When submitting this form:

- Do NOT provide any protected health information.
- Allow up to one week for a reply.

OOS Member Name:

First Name
Last Name

Organization/Practice

Your Information/Submitted by:

Name
Designation (MD, DO, MPH, COA, COT, CPC, etc.)
Job Title

Email Address

Phone Number

Phone Type:

Which payer is this problem/question related to?

(Be specific, i.e., If it is a traditional Medicare or Advantage plan, etc.)

Please provide a brief description of the problem/question/summary of the issue.

If relating to a claim, include:
- Date of service
- A copy of the claim or claim information for CPT, ICD-10 codes, modifiers, etc.
- If related to an operative report, please attach report
- Include any actions you have taken to resolve the issue

DO NOT PROVIDE ANY PROTECTED HEALTH INFORMATION.

Number of pages you are submitting:
   - denotes required fields