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  CMA Seeks Your Feedback: Have you, or a Medicare beneficiary you know, been required to wait for prior authorization or go through a pre-claim review procedure in order to receive your Medicare covered services, supplies or equipment? Please share with us your experiences on the process and the outcome. Your stories help us to advocate for you and to provide valuable feedback to CMS. Thank you!
 
1. I am discussing "Pre-claim Review"/"Prior Authorization" from the perspective of: *
      
 
 
 
2. My Name: *
 
 
 
3. Contact Email Address: *
 
 
 
4. State in which services took place: *



 
 
 
5. Beneficiary Zip Code: *
 
 
 
6. Beneficiary enrolled in: *
      
 
 
 
7. Your Phone Number: *
 
 
 
8. Please share your experiences with "Prior Authorization" or "Pre-Claim" requirements: *
 
 
 
9. Can we share this story (without identifying you unless given express permission) with: *
       		 
 
 
10. Are you willing to speak with the media? *