Retroactive Denials Survey
Select County Medical Society
*
Please Select
Broward County Medical Association (BCMA)
Clay County Medical Society (CCMS)
Dade County Medical Association (DCMA)
Duval County Medical Society (DCMS)
Nassau County Medical Society (NCMS)
Physicians Society of Central Florida (PSCF)
Practice Name
*
Name of Contact for Follow Up
*
First Name
Last Name
Email of Contact for Follow Up
*
example@example.com
Name of Procedure/Service Denied
*
Date of Service
*
Dollar Amount of Service Retroactively Denied
*
Upload Documentation with patient information redacted (Denial Letter)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: