Healthcare Complaint Form (Internal)

Fields marked with (*) are required.

Source Type*

OAG Rep*

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.

Your Information

Name*

Salutation First Last

Age

Address*

Street Address City State Zip Code

County*

Best Phone Number*

Please only enter numbers

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

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

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

Other

Have you contacted other agencies?

Yes

If yes, provide name of agency and contact person

Has This Matter Gone To Collections?

Yes

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

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: 256 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

Other

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Print Name

First Last

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Authorization Date

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Date of Birth

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SSN (Last 4 Digits)

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Medical release authorization

By checking, I,

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(Print Name)

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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)

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If representative, identify type/source of authority

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hash

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Signed Form

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Your Signature (File)

Max. file size: 256 MB.

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Signature of Individual/Authorized Representative (file)

Max. file size: 256 MB.

Attorney General Sunday

Office of Public Engagement

Do Not Call List

Home Improvement Contractor Registration

Your Information

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

Insurance Information

Who is the Complaint Against?

Optional Information