PATIENT DIRECT APPEAL PROGRAM

Click here to sign the PRIA Patient Consent Form electronically

To initiate the appeal process, please complete this form in its entirety. Once we receive your form, we will send you a secure email to submit your documents.

Patient Direct Appeals - Saluda

Patient Information

Patient Name
Patient Name
First Name
Last Name
Phone Type
If cell number was provided, do you consent to receiving text messages from DocuSign to obtain an electronic signature on any additional forms that may be required to submit your appeal?
Patient Address
Patient Address
City
State/Province
Zip/Postal
If we need to contact you about your appeal, what is your preferred method of contact?

Insurance Information

Is this your primary or secondary insurance?
plus1 Add Additional Insurance minus1 Remove

Performing Doctor's Information: Who is performing your SCS procedure?

Physician Address
Physician Address
City
State/Province
Zip/Postal

Facility Information: Where are you having this procedure done?

Facility Address
Facility Address
City
State/Province
Zip/Postal

Denied Authorization Details

Is the denial for your Evoke SCS Trial or Permanent Implant?

Diagnosis Information: What diagnosis code(s) did your physician submit the authorization with?

Is this a primary diagnosis code or a secondary diagnosis code?
plus1 Add Additional Diagnosis Code minus1 Remove

Procedure Codes: What codes did your physician submit for on the authorization and how many units?

plus1 Add Additional Procedure Code minus1 Remove

Questions? P 860-374-2743 E saludamedical@priahealthcare.com H Monday-Friday 8:30a-8p est