| 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:
|
| *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 |