Hassle Factor Form

Physician confidentiality will be maintained.


What kind of comment would you like to send?

Complaint   Problem   Suggestion

Please enter the following information:

ACC Member Number:
Office Address:
Address2:
City:
State:     Zip Code:  
Office Phone Number:
Fax Number:
Email:*
*mandatory
Contact Person:
Name of Health Plan:
Type of Plan/Carrier:

Please choose the Type of Problem from the following list provided below:

Billing/Claim Hassles:

Please provide a brief summary of the Hassle in the space provided below:

Related CPT Code(s):

Other (specify):  

Is this a...
First time problem?    Recurring problem?   
Time Sensitive?

Have you contacted your local Chapter?   Yes    No

Please specify how we can be of any further assistance or any other information you want us to be aware of:

Please contact me as soon as possible regarding this matter by:

   FAX   PHONE   E-MAIL    Other:

You may phone the Payor Advocacy Department with any further questions:  (800) 435-9203 ext. 607.

  


Practice Organization and Management Division.
Copyright © 2000 American College of Cardiology.  All rights reserved.
Revised: February 23, 2000.
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