Insurance Complaint Form

 Carrier Information
 
Name of Carrier:  
Address:
City:  
State:
Zip:
Carrier Phone #:
Is the plan self-funded or self-insured?:  
Is the claim under a network provider?:  
Name of Network:
 
 Claim Information
 
Type of Problem:
 
Without disclosing Protected Health Information (PHI), please describe briefly the nature of the claim issue:
    
 
Do you have documentation of the problem you described above?:
 
If you answered "Yes" to the last question:
Claim No.:
 
Describe the type of documentation you have:
 
 
 Physician Information
Physician Name:
Address:
City:
State:
Zip Code:
Specialty:
Phone:
Fax:
Email Address:
Date:  [None] Select a Date Delete the Date  
Contact Person: