Prior Authorization Form

Prior Authorization Experience Form
Prior Authorization (PA) is one of the most significant issues TMA members face. We'd like to hear about your experience in order to learn more about your point of view. This becomes essential when discussing the topic with lawmakers.

Please fill out the form below to provide us with details.
Your Name *

First Name Last Name
Your Email Address: *
example@example.com
Your Preferred Phone Number:
Either your work, home or cell phone number.
Practice/Company involved: *
The year(s) this experience occurred:
I am a: *

Patient Physician or Provider Health Care Team Staff
Describe your Prior Authorization experience (please do not include any patient identifier information.):
Please pick all that apply. *

I consent to share this story with TMA for their use in support of the campaign to ease prior authorization burdens that delay or deny care for patients. I am willing to share my story with a lawmaker and/or in front of a panel. I do not want my story shared publicly.
Can a TMA staff member reach out to you for further information? *

Yes No
Should be Empty:

Prior Authorization Experience Form