Health Care Complaint Form

Fields marked with (*) are required.

Please check if you or an immediate family member is a member of the military or a veteran.

Please check if you or an immediate family member is a member of the military or a veteran.

Please check if you are age 60 or older.

Please check if you are age 60 or older.

Your Information

Name *

Salutation First Last

Age

Address *

Street Address City State Zip Code

County *

Best Phone Number *

Please only enter numbers

Email

Enter Email Confirm Email

If completing this form on behalf of someone else, please complete the following information:

Name

Salutation First Last

Relationship to consumer

Address

Street Address City State Zip Code

County

Best Phone Number *

Please only enter numbers

Email

Enter Email Confirm Email

Insurance Information

Insurance Company

Phone Number

Please only enter numbers

Subscriber's Name

First Last

Policy Number

Group Number

Patient's Name

First Last

Date of Birth

Relationship to Subscriber

Type of Insurance

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

Yes
No

If yes, provide the outcome of the appeal:

Who is the Complaint Against?

Business Name *

Person To Whom You Spoke

First Last

Business Phone Number

Please only enter numbers

Address

Street Address City State Zip Code

County

Product or Service Purchased

Date Purchased

Purchase Price

Form of Payment

Cash
Check
Credit Card

Have you contacted other agencies?

Yes
No

If yes, provide name of agency and contact person

Has This Matter Gone To Collections?

Yes
No

If yes, provide name of the Collection Agency

If yes please also provide the address of the Collection Agency

Street Address City State Zip Code

County

Is there or has there been a court action regarding this matter?

Yes
No

If yes, please provide the court name

If yes, please also provide the case number

If yes, please also provide the outcome of the case

Please briefly explain your complaint

Explain WHAT happened, WHEN it happened, and WHERE it happened. ATTACH COPIES of all applicable insurance contracts or policies, medical bills, explanations of benefits, correspondence, receipts, cancelled checks (front & back), advertisements or any other papers that relate to your complaint. Please complete and sign the attached "Authorization to Release Medical/Insurance Records and Information." PLEASE TYPE or PRINT your explanation. If additional space is needed, please use additional paper and attach to complaint form.

Complaint File Uploads

Drop files here or

Max. file size: 100 MB.

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.

What Specific Resolution Are You Seeking In Order To Settle Your Complaint?

Optional Information

How did you hear about us?

What is your race or ethnicity?

Hispanic/Latino
White(Not Hispanic/Latino)
Black/African American (Not Hispanic/Latino)
Native Hawaiian/Pacific Islander
Asian
Native American
Biracial

PLEASE READ CAREFULLY

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 subject to our document retention policies and applicable law and the information contained in it may be used to establish violations of Pennsylvania law.

By signing below:

I understand that filing a complaint with HCS does not preserve my private right to sue, or my appeal rights pursuant to ACT 68, Medicare, or any insurance contract or policy.
I authorize 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.
I authorize HCS to share my complaint with, or refer my complaint to, another federal, state, local, or other agency. This authorization extends to any or all information and attachments which may be part of my case file, including any medical records the Office obtains pursuant to my medical release.
By completing and submitting this complaint form, I authorize HCS 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 HCS. I verify that I have read and understand the information in this complaint form and any attached forms or correspondence, and that the information provided is true and correct to the best of my knowledge, information and belief.

Print Name

First Last

Your Signature *

Authorization to Release Medical/Insurance Records and Information

THIS FORM HELPS US OBTAIN RECORDS OR OTHER INFORMATION NEEDED TO ADDRESS YOUR COMPLAINT. PLEASE COMPLETE, SIGN, AND RETURN AS SOON AS POSSIBLE.

Authorization Date

Date of Birth

SSN (Last 4 Digits)

Medical release authorization

By checking, I,

(Print Name)

herby authorize the release of my insurance, financial and medical records, and the disclosure of information from such records, to:

Office of Attorney General
Health Care Section
Strawberry Square, 14th Floor
Harrisburg, PA 17120
T: (717)705-6938 F:(717)787-1190
Email: healthcare@attorneygeneral.gov

Purpose of Authorization: Mediation, investigation, and/or enforcement action for consumer complaint.

Entities Covered by Authorization: Physician or medical practitioner; hospital or health clinic or facility; insurance company; third party administrator; employer; debt collector; pharmacy; and/or any other entity or person in possession of such records or information.

Expiration of Authorization: Conclusion of mediation, investigation, and/or enforcement action.

If applicable to your complaint, check below to release specific records or information:

Specific records release

Alcohol/Drug Abuse Treatment/Referral
Mental Health (Other than Psychotherapy Notes)
Sexually Transmitted Diseases
HIV/AIDS-related Diagnosis/Treatment
Psychotherapy Notes ONLY (by checking this box, I am waiving any psychotherapist-patient privilege)

I also understand that: (1) I have the right to revoke this authorization in writing to HCS, except to the extent action has been taken relying on this authorization;(2) I have a right to a copy of this authorization; and (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 on signing such authorization.

I further authorize the Office of Attorney General to redisclose this information to other federal, state, local, or other agencies, or otherwise as necessary and permitted by law to take action on my complaint. I also understand that information disclosed by this authorization, except for Alcohol and Drug Abuse as defined in 42 CFR Part 2, or otherwise prohibited by applicable law, may be subject to redisclosure, and may no longer be protected by the HIPAA Privacy Rule [45 CFR Part 164], the Privacy Act of 1974 [5 USC 552a], and/or other state, federal, or local law.

Signature of Individual/Authorized Representative *

If representative, identify type/source of authority

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