Complaint or appeal form

I want to report a complaint or appeal

1. Complaint details

Tell us about the complaint or appeal. Be sure to complete all fields with an asterisk (*).

*Check the one that applies:

I’m filing a complaint.

I’m filing an appeal.

*Date Date of event or notice of denial

*What happened

Tell us about your complaint or appeal.

2. Member info

Fill out your info. Be sure to complete all fields with an asterisk (*).

*Name

*Date of birth

*Address 1

Address 2

*City

*State

*Zip Code Example: 12345

*Phone Number Example: 1234567890

*Member plan ID number

*Are you filing this complaint or appeal for someone else?

Yes, I’m a representative.

No, I’m the member.

You’ll need to show proof of power to represent the member. Members can choose representatives to act for them, like family, friends, caregivers or providers. You can mail, fax or email this proof (a signed letter) to us. Check our “Contact us” page to get in touch.

3. Your info

Fill out your info. Be sure to complete all fields with an asterisk (*).

*Name

*Relationship How you know the member

*Date of birth

*Address 1

Address 2

*City

*State

*Zip Code Example: 12345

*Phone Number Example: 1234567890

Note: Expedited (faster) decision

Is our standard time frame of 30 days too long to wait for a decision? Ask for an expedited appeal if you or your provider believe waiting will put your life or health in danger.

Check this box if you believe you need a decision within 72 hours. If your provider agrees, you can mail, fax or email their statement to us. Check our “Contact us” page to get in touch.

*Sign

*Date Today's date

*Who signed

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Complaint or appeal form

I want to report a complaint or appeal

1. Complaint details

2. Member info

Note: Expedited (faster) decision

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