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Health Care Complaint Form

Please Note: As part of the complaint handling process, the Health Care Section may send a copy of this form to the individual or company against whom your complaint is filed. Failure to supply your complete and accurate contact information may result in delayed processing of your complaint.

Filing a complaint with the Office of Attorney General does not preserve your appeal rights pursuant to your insurance contract or any applicable laws. To preserve your rights, you must file an appeal (complaint or grievance) directly with your health insurer/administrator in conformance with the terms of your coverage.

* indicates required field


Age Group

                  



Your Information

Title

Your Name *

Address *

City *

State *

County *

Zip Code *

Daytime Phone Number *

 

Home Phone Number *

 

Email *

 

Age Group

                                      

Title

Their Name *

Address *

City *

State *

County

Zip Code *

Daytime Phone Number

Home Phone Number

Email

 

Who is the complaint against?

Business Name *

Person to whom you spoke

Address *

City *

State *

County

Zip Code

Phone Number

 

 

Insurance Information

                             

If other, enter Insurance Type

Insurance Company Name

Insurance Company Phone

Subscribers Name

Policy Number

Group Number

Patient's Date of Birth

Patients relationship to subscriber

 

Did you file a formal appeal (complaint or grievance) with your health plan?

                             

If yes, what was the outcome?

 

 

Complaint Information

Products or Services Purchased

 

Date of Purchase

Purchase Price

Payment Method

If other, enter other payment method

Are you requesting a refund?

                             

If yes, amount of refund requested

 

Has this matter been submitted to another agency?

                                                          

If yes, please provide name and address.

 

 

Has this matter gone to collections?

                                                          

If yes, please provide name and address of the collection agency.

 

 

Please briefly explain your complaint. Tell WHAT happened, WHEN it happened, and WHERE it happened. Describe the events in the order in which they happened.

 

 

What specific resolution are you seeking in order to settle your complaint?





Read the following carefully before signing below:

The Attorney General cannot act as your private attorney. As a law enforcement agency, the primary function of the Office of Attorney General is to represent the public at large by enforcing laws including those prohibiting fraudulent, deceptive, confusing or misleading trade practices. Through the Health Care Section (HCS), the Attorney General does provide a service to consumers through this mediation unit, to resolve individual consumer complaints. The information you provide in this form will be used in an attempt to resolve your complaint and will be shared with the party(ies) against which the complaint is filed. Your complaint will remain on file with our Office and the information contained in it may be used to establish violations of Pennsylvania law.
  
By signing below:
  1. I understand that filing a complaint with the HCS does not preserve my private right to sue, nor my appeal rights pursuant to Act 68, Medicare, or any insurance contract or policy. 
  2. I authorize the HCS to provide a copy of this complaint to any person or company about which I am complaining; and to any person or provider possessing medical and insurance records or information related to the complaint.
  3. I authorize the HCS to transfer my complaint to another federal state, local, or other agency which may have jurisdiction over this matter. This authorization extends to any or all attachments which may be part of my case file, including any medical records the Office may obtain pursuant to my medical release.
  4. By completing and submitting this complaint form, I authorize the Health Care Section to contact the party(ies) against which I have filed a complaint in an effort to reach an amicable resolution. I further authorize the party(ies) against which I have filed a complaint to communicate with and provide information related to my complaint to the Health Care Section. I verify that I have read and understand the informational sheet about this process and that the information provided is true and correct to the best of my knowledge, information and belief. 
 
 
Please note: In order to execute this document, type your full name in the space provided below. 

Signature*

Date *

 


Authorization to Release Medical and Insurance Records

Please read and submit the following medical/insurance release authorization. Entry of your name below is required in order to process your complaint.

I hereby authorize any of the following: physician or medical practicitioner; hospital or medical clinic or facility; insurance company; third party administrator; employer; debt collector; pharmacy; or other provider or person in possession of any of the medical and insurance records for

(Name of patient*)

to release the records and information, as described below, to:

Office of Attorney General

Health Care Section

14th Floor, Strawberry Square

Harrisburg, Pennsylvania 17120

(717)705-6938 

These records should relate to the complaint I, or my authorized representative, filed with the Office of Attorney General. The purpose of this authorization is to aid the Health Care Section in the investigation of my complaint.

I authorize the Office of Attorney General, Health Care Section, to disclose any information obtained pursuant to this Authorization, along with the other information contained in its case file, to such other federal, state, local or other agencies as deemed appropriate.

I understand that: (1) I have the right, upon written notification to the Office of Attorney General, to revoke this authorization. However, this authorization may not be revoked if the Attorney Generals employees/agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization; (2) Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a covered entity may not condition treatment, payment, enrollment, or eligibility for benefits if I refuse to sign such authorization; and (3) information disclosed pursuant to this authorization is subject to re-disclosure by the Office of Attorney General and will no longer be protected by applicable federal and state privacy laws.

This authorization expires upon the conclusion of the investigation into the complaint by the Office of Attorney General.

Please note: In order to execute this document, type your full name in the space provided below.

Signature of Individual or Authorized Personal Representative*

Description of Personal Representatives Authority *

Date *

 

Authorization to Release Medical and Insurance Records Related to Substance Abuse

(Please read and submit the following authorization only if your complaint is relative to substance abuse treatment. You must also fill out the "Authorization to Release Medical/Insurance Records" section above.)

 

(enter Name)

hereby authorize

Provider - (enter name of physician or medical practitioner; hospital or other clinical facility; insurance company; and/or third party administrator)

possessing the medical and insurance records of

Patient - (enter name of individual/patient)

to release the records and information, as described below, to:

Office of Attorney General

Health Care Section

14th Floor, Strawberry Square

Harrisburg, Pennsylvania 17120

(717)705-6938 

These records should relate to substance abuse treatment as identified in the complaint I, or my authorized representative, filed with the Office of Attorney General. The purpose of this authorization is to aid the Health Care Section in the investigation of my complaint.

I authorize the Office of Attorney General, Health Care Section, to disclose any information obtained pursuant to this Authorization, along with the other information contained in its case file, to such other federal, state, local or other agencies as deemed appropriate.

I understand that: (1) my substance abuse records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR Part 2), and cannot be disclosed without my written consent unless otherwise provided for in the regulations; (2) I have the right, upon written notification to the Office of Attorney General, to revoke this authorization, except to the extent that action has been taken in reliance upon it; (3) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a covered entity may not condition treatment, payment, enrollment or eligibility for benefits if I refuse to sign such authorization; (4) information disclosed pursuant to this authorization is subject to re-disclosure by the Office of Attorney General and will no longer be protected by applicable federal and state privacy laws.

This authorization expires upon the conclusion of the investigation into the complaint by the Office of Attorney General.

Please note: In order to execute this document, type your full name in the space provided below.

Signature of Individual or Authorized Personal Representative

Description of Personal Representatives Authority

Date