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Complaint Form


Click here for the complaint Form in LARGE PRINT

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This form is for complaints. If you would like to file an appeal, please call the number on the back of your insurance card.

* Required
Your complaint is about (select one): *
Clinician or Facility
Other
Are you filling out this form for yourself or for someone else? *

  Other:
*
  

Check if address is same as enrollee's
Enrollee Information
Please fill out the following information:

For the purposes of this form, the "Enrollee" is the person to whom the services were rendered.
Enrollee First Name *
Enrollee Last Name *
Enrollee Address *
Enrollee City *
Enrollee State *
Enrollee Zip *
Enrollee Phone *
- -  Type:
Alternative Phone
- -  Type:
Enter extension or international phone number in the complaint textbox below.
Enrollee Date of Birth *    
Subscriber Name
Relationship to Subscriber    Other:  


If you are completing this form on behalf of the enrollee, please include your name, address, phone number and your relationship to the enrollee:

First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
*
Phone
*
- -   Type:
Alternative Phone
- -   Type:
Enter extension or international phone number in the complaint textbox below.



Complaint *
Please describe your complaint in as much detail as possible. Please include dates and names. Written acknowledgement of your complaint will be provided within five (5) calendar days of our receipt; written resolution to your complaint will be provided within 30 calendar days of our receipt.

Do not hit "Enter" or click the "Back" button prior to completing this section. You will have a chance to review and make revisions prior to submitting this form.



Please describe the outcome(s) you are seeking at this time.


In order to conduct a thorough investigation of this complaint, we may need to use your name. Do you wish to remain anonymous? *
No
Yes

Provider Information
Please select provider type: *
Clinician
Facility

Please provide the name, address and phone number of either the clinician or facility involved in this report: *

Clinician -or- Facility
First Name
*
Facility Name
*
Last Name
*
Address
Group Name City
Address State
*
City Zip
State
*
Phone
*
--
Zip
Phone
*
--


To send your complaint:
Please click the "Submit" button below


   




Provider Information
If applicable, please provide the name, address and phone number of the psychiatrist or other behavioral health care provider involved in this report.

Provider Name
Provider Address
Provider City
Provider State
Provider Zip
Provider Phone - -

To send your complaint:
Please click the "Submit" button below


   



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