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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

View All News

Sep

Britt Thedinger, MD, installed as 2018-19 President

Aug

American Academy of Pediatricians Updates Car Seat Recommendations

Jul

CMS releases 2019 fee schedule*

Jun

AMA Summary Explains House Opioid Legislation

View All Events

Oct

2018 Webinar Series - Healthcare Guardians

Feb

2019 Annual Advocacy Breakfast

News + Events

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