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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

04

Renewal Update as of 1/4/2021

Dec

18

Nebraska License Renewal Update

Nov

16

AMAF Honors Alena Balasanova, MD with Health Education Award

Oct

01

Renewals are currently on hold, per Executive Order 20-10

Come back again and check for more upcoming events!

News + Events

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