Carrier Advocacy Request

The society has developed this form for members to submit carrier information when denied reimbursement to the physician or the patient for specific interventional radiology treatments. To initiate societal “Comment Letters” please complete the information below.

*documentation should be redacted of patient/physician information.

Member Information

SIR Membership number

Your SIR membership number can be found in your online member profile at https://www.sirweb.org/myaccount

First Name

Last Name

Email Address

Phone Number

Have you contacted the Carrier ?

YesNo

Carrier Infromation

Please provide us with information pertaining to the Carrier.

Identify Carrier

Carrier Contact Person

Address Line 1

Address Line 2

City

State

Zip

Phone Number

Denial Reason

Please attach a copy of the denial letter.

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