Provider Contact Information

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RAC Request for Provider Contact Information

Performant Recovery is the Recovery Audit Contractor (RAC) for Regions 1 and 5. Please provide your contact information for both Medical Record Requests and Review Results Letters/Discussion Period Letters below. If you represent multiple facilities/providers, please complete this form for each facility/provider or you can complete the Excel spreadsheet linked below. If you utilize the Excel spreadsheet, email the completed form to our RAC Customer Service Team.

Please indicate your State *
Provider Name *
NPI # *
Hospital/Physician Group Name *
Same as NPI(Note: If you are a hospital your NPI# and your Group NPI# are the same #.)
Tax Identification # *
Group NPI # *
Does your facility/office bill under any other NPIs?
Contact Person *
Telephone # *
Title
Fax #
Mailing Address *
City *
State *
Zip Code *
Alternate Contact Person
Telephone #
Check Correspondence
Contact Person
Telephone #
Title
Fax #
Mailing Address
City
State
Zip Code
Alternate Contact Person
Telephone #
 
Enter the code shown above.