CALLER INFORMATION:
Caller Name:
Practice Name:
Tax ID (If Applicable):
Phone Number:
Email Address:
Summary of Call/Issue:
Post-Call Questions:
Do I need to send any paperwork to the Provider? If Yes, What?
Did I promise to Follow-up? If Yes, when?
Does this require a Director or TL input/Assistance?
Is there another team I need to get involved? If Yes, what team?
ADDITIONAL NOTES:
FOLLOW-UP:
URGENCY:
☐ High (Immediate Action Required)
☐ Medium (2-3 Business Days)
☐ Low (No Immediate Action Required, can take beyond 3 Business Days)
POST CALL ACTION STEPS: