Provider Filing Form

Please capitalize the first and last name of the patient, the person filing the complaint, the health insurance carrier and any doctor or provider.
* Denotes Required Fields

Patient Information
Title (e.g. Mr., Mrs., Miss, Dr.):
*First Name:
*Last Name:
*Address: (Please note: in order to assist you, it is important for us to have the full address of the patient.):
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
Please list the name of the parent, guardian or representative, if applicable. Describe the relationship to the patient. List address and contact information, if different.
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:
*Membership Number (refer to the copy of the insurance card): Add Another
Information about a doctor or health care provider
Please complete the following information about the doctor or health care provider.

If this is the first time your office is filing a complaint on behalf of a consumer, or if your information has changed, please fill out ALL of the fields below. If you have previously filed complaints with this office, please fill out the fields that are red.
*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.):
Business Address Line 2 (if necessary):
Business City:
Business State:
Business Zip Code:
*Person in the office to contact regarding this complaint:
*Contact person's Phone Number:
Contact person's Fax Number:
Contact person's E-Mail Address:
How did you hear about our office?
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:

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

In the course of handling the complaint, it is often necessary for our office to obtain medical or insurance claim records and to discuss your patient's medical information with providers, the insurance plan, and other state agencies. If you have a copy of the signed form for your patient, please include it when you mail the copy of the confirmation page. Otherwise, the Health Education and Advocacy Unit will have to contact the patient for this authorization before we can proceed.

Depending upon the nature of the complaint, we may not be able to begin our efforts until the Authorization for the Release of Medical Information to the Health Education and Advocacy Unit has been received.

Please mail:
1) a copy of your confirmation page,
2) a copy of the claim form your office submitted to the health insurance carrier, and
3) a signed medical authorization form (if on file.)

Mail to:
Office of the Attorney General
Health Education and Advocacy Unit
200 St. Paul Place, 16th Floor
Baltimore, MD 21202

If you have any questions, please contact our office at:
(410) 528-1840 telephone
Toll-free in Maryland: 1-877-261-8807
(410) 576-6571 facsimile
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

* 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.