UMPC Complaint (Temp)

Veteran Status

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

Senior Status

Please check if you are age 60 or older.

Your Information

Salutation

Name *

First Last

Address

Street Address City State Zip Code

County

Best Phone Number *

Alternative Phone Number (Optional)

Email

Enter Email Confirm Email

Age (optional)

Who is the Complaint Against?

UPMC
Highmark
Both

Insurance Information

Insurance Company Name

Insurance Company Phone

Subscriber’s Name

First Last

Policy Number

Group Number

Patient's Date of Birth

Patient’s relationship to subscriber

Insurance Type

Complaint Information

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.

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. Upload 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 “Authorization to Release Medical/Insurance Records.” PLEASE TYPE or PRINT your explanation. If additional space is needed, please use additional paper and attach to complaint form.

Complaint Summary

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

In order to fully evaluate your complaint, we will need you to answer the following questions.

1. Do you have Highmark Insurance?

Yes
No

2. Are you attempting to access a UPMC doctor(s)?

Yes
No

Name of the doctor(s)

Name of the practice(s) including address(es) and phone number(s)

Reason why you are visiting this (these) doctor(s)

3. Are you trying to access a UPMC facility?

Yes
No

Which Facility?

4. Is the care you are seeking related to a prior or ongoing underlying medical condition?

Yes
No

What is the original condition?

5. Have you seen a UPMC doctor(s) in the past for this issue or a related issue?

Yes
No

When have you seen a UPMC doctor(s)?

Please provide the name(s) of the doctor(s) and the treatment you received.

6. Are you unable to locate a suitable doctor in your network or geographical area?

Yes
No

7. Are you being treated for cancer or any cancer related illnesses?

Yes
No

8. Have you recently been seen at a hospital in the Emergency Room?

Yes
No

Please list the name of the hospital and reason for your visit

9. Are you pregnant or did you recently give birth?

Yes
No

Please provide the date of your confirmed pregnancy

Please provide the date of your delivery

Are you experiencing any medical issues or difficulties related to the pregnancy/birth? If so, please provide a brief description of your problem.

10. Are you Medicare eligible? (Medicare eligible recipients are 65 years of age or older.)

Yes
No

11. Are you currently battling a serious or rare illness or do you require a special procedure or operation which can only be provided by a UPMC doctor or facility?

Yes
No

Please explain

12. Have you recently had a procedure at a UPMC facility and you feel the charges are too high?

Yes
No

Please explain and provide only the most recent version of related bills, invoices and/or statements.

If possible, please upload your contract, proof of payment, and other documentation to help us better understand your complaint. [UPLOAD BELOW.] Accepted formats include [fill in]. If you do not have a scanner, please upload photo of the documents. Please include any relevant emails or screen shots of text messages. If you prefer, you may email your documents to [email address].

Complaint File Uploads

Drop files here or

Max. file size: 50 MB, Max. files: 25.

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:

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.
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.
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.
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, sign your below with your mouse or finger

Signature

Date

Authorization to Release Medical and Insurance Records

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 practitioner; 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

First Last

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 General’s 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, Sign your name in the space provided below.

Signature of Individual or Authorized Personal Representative

Description of Personal Representative’s Authority

Date

Is your complaint relative to substance abuse treatment?

No
Yes

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.)

Untitled

By checking, I,

(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 Representative’s Authority

Date

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