If the complaint does not involve health insurance, click your browser's "Back" button and select one of the first two forms under the heading "Pick Your Complaint Form."
Please capitalize the first and last name of the patient, the person filing the complaint, the health insurance carrier and any doctor, provider or other business.
* Denotes Required Fields

Patient Information
Title (e.g. Mr., Mrs., Miss, Dr.):
*First Name:
*Last Name:
*Address:
Address Line 2 (if necessary):
*City:
*State:
*Zip Code:
*County: Please check here, if you are not a Maryland Resident.
If you are a Maryland resident, please check off the box indicating the county in which you reside:
Baltimore RegionWestern Maryland
Anne ArundelAllegany
Baltimore CityGarrett
Baltimore CountyWashington
CarrollUpper Eastern Shore
HarfordCaroline
HowardCecil
Suburban WashingtonKent
FrederickQueen Anne's
MontgomeryTalbot
Prince George'sLower Eastern Shore
Southern MarylandDorchester
CalvertSomerset
CharlesWicomico
St. Mary'sWorcester
*Best Telephone Number to Use During the Day:
Alternate Telephone Number:
Fax Number:
E-Mail Address:
*Patient's Date of Birth. Use mm/dd/yyyy format:
How did you hear about our office?
Information About the Person Filing the Complaint
If you are the patient, please skip this section and proceed to the section entitled "Insurance Information."
Title (e.g. Mr., Mrs., Miss, Dr.):
First Name:
Last Name:
Address:
Address Line 2 (if necessary):
City:
State:
Zip Code:
Best Telephone Number to Use During the Day:
Alternate Telephone Number:
Fax Number:
E-Mail Address:
Your Relationship to the Patient:
Insurance Information
Please complete the following information about the health insurance covering the patient.
*Primary Insurance Carrier/HMO or Health Plan:
*Policy holder first and last name:
Group Name or Number (refer to your insurance card): Add Another
*Membership Number (refer to your insurance card): Add Another
*Does this complaint concern a Marketplace/Exchange policy?
*Have you received a letter or Explanation of Benefits from the Carrier?
*Have you received an Adverse Coverage Decision Letter? NoYes
If so, what is the date of the Adverse Coverage Decision Letter? Use mm/dd/yyyy format:
Have you appealed the Carrier's decision?
Date appeal was filed with the Carrier. Use mm/dd/yyyy format:
Information about a doctor, health care provider or business
Please complete the following information about the doctor, health care provider or business involved in your health care dispute.
*Name of Doctor or Business:
*Business Address (Please note: in order to assist you, it is important for us to have the full address of the business. If you are not able to provide the business' address please write "unknown"):
Business Address Line 2 (if necessary):
*Business City:
*Business State:
*Business Zip Code:
*Business Telephone Number (Please note: in order to assist you, it is important for us to have the telephone number of the business. If you are not able to provide the business' telephone number, please write "unknown"):
Business Fax Number:
Business E-Mail Address:
Business Web Address:
If there is another doctor, health care provider, or business involved in your dispute, please complete the following:
Business Name:
Business Address:
Business Address Line 2 (if necessary):
Business City:
Business State:
Business Zip Code:
Business Telephone Number:
Business Fax Number:
Business E-Mail Address:
Business Web Address:
Please list any other doctors, health care providers, or businesses that you have not already listed:
Information about the incident involved in this complaint
*Has the patient received the service or care?
If yes, when was the service or care received?
*Describe the problem with the health insurance carrier, the health plan or the doctor or other provider:
If the complaint involves a delay in medical treatment could result in loss of life, serious impairment to a bodily function, serious dysfunction of a bodily organ, or the member remaining seriously mentally ill with symptoms that cause the member to be in danger to self or others, please describe the medical treatment and the consequences of a delay:
*Do you have any documents that support your complaint, such as an Explanation of Benefits, an Adverse Coverage Decision Letter or a Billing Statement from the doctor or provider? NoYes
Please list the type of documents you have to support your complaint:
*What would you like the carrier or provider to do to resolve your complaint?
Other Information Regarding Your Complaint
Have you filed a complaint with another governmental agency? NoYes
If so, which agency?
Have you contacted an attorney or filed a lawsuit in this matter? NoYes
After reviewing your submission, we may determine that we are not the appropriate agency to handle your complaint. If this occurs we will forward your complaint to the appropriate agency and notify you in writing.
*Do you authorize the HEAU to release your complaint information to another agency? NoYes

NOTE: After you select the Submit button, you will not be able to change any of your information. Please scroll back through the form now to verify your information. Once this form is complete select the Submit button, then print your confirmation page.
Instructions for forwarding the Authorization for the Release of Medical Information to the Health Education and Advocacy Unit and documentation supporting your complaint
Please remember that it is important for us to have copies of all relevant documents to properly handle your complaint. Please mail a copy (do not send originals) of the following documents to the Consumer Protection Division:

1. A copy of your confirmation page.

2. A copy of any bills, records or correspondence that relate to your complaint.

3. A copy of any correspondence you have received from your insurance carrier that relate to your complaint.

4. The Authorization for the Release of Medical Information to the Health Education and Advocacy Unit.

In the course of handling your complaint, it is often necessary for our office to obtain medical or insurance claim records and to discuss your medical information with providers, your insurance plan, and other state agencies. You must authorize us to obtain your medical records and discuss them with other relevant parties. Please download and complete the Authorization for the Release of Medical Information to the Health Education and Advocacy Unit so that we may obtain and review medical or claim records for care provided to you or a member of your family.
Depending upon the nature of your complaint, we may not be able to begin our efforts to assist you until your supporting documents and the Authorization for the Release of Medical Information to the Health Education and Advocacy Unit have been received.
If you are unable to print a confirmation page, please mail a copy of your supporting documents along with the following information:
Patient Name
Name of Person Filing the Complaint
Date You Filed This Complaint by Internet
Reference Number
Send To:
Office of the Attorney General
Consumer Protection Division
Health Education and Advocacy Unit
200 St. Paul Place, 16th Floor
Baltimore, MD 21202
(410) 528-1840 telephone
Toll-free in Maryland: 1-877-261-8807
(410) 576-6571 facsimile
* Denotes Required Fields

If you experience a problem while trying to submit your complaint, you may contact our office at 410-528-1840, Monday through Friday from 9:00 a.m. to 4:30 p.m. or send an e-mail describing the problem to: heau@oag.state.md.us You will receive a response during regular business hours.