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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

Nov

12

AMA Releases Summary of 2019 Medicare Physician Fee Schedule and Quality Payment Program Final Rule

Nov

05

Nebraska Tobacco Cessation Week November 12-16

Nov

02

Physicians should be aware of new DEA extortion scam

Sep

17

Britt Thedinger, MD, installed as 2018-19 President

View All Events

Feb

12

2019 Annual Advocacy Breakfast

News + Events

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