Physician or Clinic Name Contact Person Title Address Phone FAX Carrier or Agency Involved (i.e., Medicare, HMO, PPO, capitation, private, etc.) Contact Person with the Carrier or Agency Phone Number of Contact Person with Carrier or Agency Following the process described in this paragraph will greatly assist CODEFAX in responding to your inquiry. For each problem or question submitted: 1) Be as informative as possible as to the patient status, chief complaint, and your coding/reimbursement concerns. 2) If you have received a rejection, please provide us with a copy. If you have asked for a review, let us know. If you are involved in a peer review, audit or legal action, please let us know the situation. 3) If there is a dispute, or question, in your office over diagnoses or the diagnoses codes that would properly support the procedures, let us know the specifics along with your question. 4) For confidentiality, always omit or block out the patient name and I.D. Please attach separate sheets if necessary. Inquiries should be sent by FAX to: (847) 391-9711. Question and/or Brief Description of Problem: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Note: Please duplicate copies of this form for your file and future use.