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Insurance Complaint Form

Insurance Complaint Form

Carrier Information

Name of Carrier

Address

City

State

Zip Code

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?

Claim No.

Describe the type of documentation you have

Physician Information

Physician Name

Address

City

State

Zip Code

Specialty

Phone

Fax

Email Address

Date

Month

Day

Year

Contact Person

Members Page

News
Events

Jan

29

NMA STAT Newsletter: January 27, 2020

Dec

11

Atlantic Health Partners Expands Its Program to Offer Additional Vaccine Savings!

Oct

29

Crowdfunding Campaign: Make a Gift That Has Lasting Impact - Your Donation Will Be Matched!

Oct

16

Be Safe This Halloween: Medication Can Easily Be Mistaken for Candy

View All Events

Aug

28

NMA 152nd Annual Membership Meeting

News + Events

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