RAC Request for Provider Contact Information

Diversified Collection Services (DCS) is the Recovery Audit Contractor (RAC) for Region A. 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 RAC Customer Service Liaison.

Region A Provider Contact Information Spreadsheet.xls

* Please indicate your state
* Provider Name
 * NPI #
* Hospital/Physician Group Name
 Group NPI #
* Tax Identification #
  
Does your facility/office bill under any other NPIs? Yes No
                                                                  If you checked yes, please fill out a form for each NPI.

Contact for Review Results Letters/Demand Letters
* Contact Person
 * Telephone # (no dashes)
Title
 Fax # (no dashes)
* Mailing Address
* City
 * State
  		* Zip Code
Alternate Contact Person
 Telephone # (no dashes)

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 DCS Medical Record Requests
* Contact Person
 * Telephone # (no dashes)
Title
 Fax # (no dashes)
* Mailing Address
* City
 * State
  		* Zip Code
Alternate Contact Person
 Telephone # (no dashes)

You can send this information by clicking the submit button or by faxing it to DCS RAC Customer Service at 325-224-6710.