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Provider Advocate Training Request Form
Provider Advocate Training Request Form
Please complete this form to request training for your practice. If you have a question that is not related to specific claims or patients, please complete the
Provider Education Contact Form
.
Person to contact for this training:
County
Practice/company name
Tax ID or NPI
Practice Address
Address
Address 2
City/Town
State/Province
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
Email Address
Phone number
What topics do you want covered in your training session? Check the box(es) that apply.
Precertification
My Insurance Manager
My Remit Manager
Avalon/Laboratory Management Programs
Credentialing
NDC Coding
New Office Staff Training
NIA Programs
Medical Pharmacy Programs
BlueCard
Claims/Provider Reconciliations
Quality Programs and Initiatives (HEDIS/Risk Management)
Prevention Reminders
Other (specify below)
Other topics:
How many people will attend this training?
Who will be attending this training? Check the box(es) that apply.
Biller(s)
Practitioner(s) or other Clinician(s)
Administrative (Front Desk) Staff
Other (please specify)
Other attendees:
How do you want this training delivered?
- Select -
Webinar
In person
Conference call
Email me the information
When do you want this training delivered?
- Select -
As soon as possible
Within the next week
Within the next month
This specific date:
This specific date:
The questions below are not required, however, the information you provide may be beneficial to your Provider Advocate during your requested training.
If applicable, what is the name of your clearinghouse?
Name of clearinghouse:
Not applicable
If applicable, what is the name of your medical records management vendor (copying service)?
Name of medical records management vendor:
Not applicable
If applicable, what is the name of your electronic medical records (EMR) or electronic health records (EHR) vendor?
Name of EMR/EHR vendor:
Not applicable
Leave this field blank
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