Request for peer-to-peer consultation

1. Did you receive a communication from Cohere requesting to schedule a peer-to-peer consultation? *This question is required.

Please indicate the insurance payer that pertains to this request: *This question is required.

Disclaimer: If you need to schedule your peer-to-peer urgently, please do not submit this form and call us directly at (833) 283-0033 so that we can assist you.

Your contact information:
Please provide your name and email address in case we need to contact you, the submitter of the request, directly. *This question is required.

Your name *This question is required.

Your email address
(We will use this email to send a confirmation of the peer-to-peer consultation) *This question is required. This question requires a valid email address.

Your phone number (add extension if needed)
(We will use this phone number if we are unable to schedule the peer-to-peer consultation, in order to let you know next steps) *This question is required. This question requires a valid number format.

Provider contact information:
Please note: Provider must be either an NP, PA, or MD/DO
*This question is required.

Cohere tracking ID *This question is required.

Name and title of provider *This question is required.

Phone number of provider (add extension if needed)
(This is the phone number that we will call in order to complete the peer-to-peer consult). *This question is required.

Email address of provider (to receive calendar link to schedule peer to peer) *This question is required. This question requires a valid email address.

Date & time availability preferences:
Please note: Do not provide availability for a date that is after the date required for decision (turnaround time or date of service). If a time after the turnaround time is selected for the peer-to-peer consult, we will be unable to schedule the consult and will contact you by phone to provide the next steps. See this Learning Center article for more details.

Date availability preference #1:
(Peer-to-peer consults typically last about 15 minutes) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Time availability preference #1:
(Peer-to-peer consults typically last about 15 minutes) *This question is required.

Date availability preference #2: *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Time availability preference #2: *This question is required.

Date availability preference #3: *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Time availability preference #3: *This question is required.

Request for peer-to-peer consultation

Support Request Form