| 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:
|
| 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: | |