RA Request for Provider Contact Information

Performant Recovery is the Recovery Auditor (RA) for Regions 1 and 5. Please provide your contact information for both Review Results Letters/Demand Letters and Medical Record Requests below. If you represent multiple facilities/providers, please complete this form for each facility/provider.

If you would like to fill out a spreadsheet instead of an online submission form, please fill out the spreadsheet linked below and email the completed spreadsheet to our RA Customer Service Liaison.

Excel Provider Contact Information Spreadsheet.xls

If you checked yes, please fill out a form for each NPI.   
Contact for Review Results Letters/Demand Letters
CHECK HERE IF YOU WANT ALL CORRESPONDENCE, INCLUDING MEDICAL RECORD REQUESTS, TO BE DIRECTED TO THE ABOVE INDIVIDUAL OTHERWISE, COMPLETE THE NEXT SECTION.
Contact for Performant Recovery Medical Record Requests
You can send this information by clicking the submit button or by faxing it to Performant Recovery RA Customer Service at 325-224-6710.