JOSH SHAPIRO ATTORNEY GENERAL healthcare@attorneygeneral.gov www.attorneygeneral.gov Health Care Complaint Form Health Care Section th 14 Floor, Strawberry Square Harrisburg, PA 17120 1-877-888-4877 1-717-705-6938 1-717-787-1190 (fax) Required fields are marked with an asterisk* Your information: Age Group: Are you a veteran? Are you on active duty? Yes Yes Name* No No Under 18 18-34 35-59 60-64 65 and older Mr. Mrs. Address* Ms. Dr. City* State* Zip Code* County* Daytime Phone Number* ( ) Home Phone Number* ( ) Email Address If completing this form on behalf of someone else, please complete the following information: Age Group: Are they a veteran? Are they on active duty? Yes Yes No No Under 18 18-34 35-59 60-64 65 and older Mr. Mrs. Address* Ms. Dr. Name* City* State* Zip Code* County* Daytime Phone Number ( ) Home Phone Number ( ) Email Address Who is the complaint against? Business Name* Phone Number: ( Person to Whom You Spoke ) Mailing Address Office/Suite City State Zip Code County American LegalNet, Inc. www.FormsWorkFlow.com Insurance Information: Insurance Company Telephone # ( Mailing Address ) City State Zip Code Subscriber's Name Policy No. Group No. Patient's Name Patient's Date of Birth Patient's Relationship to Subscriber Type of Insurance: (Please check) HMO PPO POS Traditional Medicare Medical Assistance Other ________________________ Yes No Did you file a formal appeal (complaint/grievance with your health plan)? If yes, what was the outcome of the appeal? Complaint Information: Products or Services Purchased Date of Purchase/Transaction Purchase Price Payment Method: Cash Check Credit Card Other If other, enter other payment method: Are you requesting a refund? Yes No If yes, amount of refund requested? Has this matter been submitted to another agency? Yes No If yes, please provide name and address. Has this matter gone to collections? Yes No If yes, please provide name and address of the collection agency. Is there or has there been a court action regarding this matter? Yes No If yes, please provide the court name, case number and the outcome of the case. American LegalNet, Inc. www.FormsWorkFlow.com Filing a complaint with the Office of Attorney General does not preserve your appeal rights pursuant to your insurance contract or any applicable laws. To preserve your rights you must file an appeal (complaint or grievance) directly with your health insurer/administrator in conformance with the terms of your coverage. Please briefly explain your complaint. Tell WHAT happened, WHEN it happened, and WHERE it happened. Describe the events in the order in which they happened. ATTACH COPIES of all applicable insurance contracts or policies, medical bills, explanations of benefits, correspondence, receipts, cancelled checks (front & back), advertisements or any other papers that relate to your complaint. Please complete and sign the attached "Authorization to Release Medical/Insurance Records." PLEASE TYPE or PRINT your explanation. If additional space is needed, please use additional paper and attach to complaint form. What specific resolution are you seeking in order to settle your complaint? American LegalNet, Inc. www.FormsWorkFlow.com PLEASE READ CAREFULLY THE ATTORNEY GENERAL CANNOT ACT AS YOUR PRIVATE ATTORNEY The Attorney General cannot act as your private attorney. As a law enforcement agency, the primary function of the Office of Attorney General is to represent the public at large by enforcing laws including those prohibiting fraudulent, deceptive, confusing or misleading trade practices. Through the Health Care Section (HCS), the Attorney General does provide a service to consumers through this mediation unit, to resolve individual consumer complaints. The information you provide in this form will be used in an attempt to resolve your complaint and will be shared with the party(ies) against which the complaint is filed. Your complaint will remain on file with our Office and the information contained in it may be used to establish violations of Pennsylvania law. By signing below: 1. I understand that filing a complaint with the HCS does not preserve my private right to sue, nor my appeal rights pursuant to Act 68, Medicare, or any insurance contract or policy. 2. I authorize the HCS to provide a copy of this complaint to any person or company about which I am complaining; and to any person or provider possessing medical and insurance records or information related to the complaint. 3. I authorize the HCS to transfer my complaint to another federal state, local, or other agency which may have jurisdiction over this matter. This authorization extends to any or all attachments which may be part of my case file, including any medical records the Office may obtain pursuant to my medical release. 4. By completing and submitting this complaint form, I authorize the Health Care Section to contact the party(ies) against which I have filed a complaint in an effort to reach an amicable resolution. I further authorize the party(ies) against which I have filed a complaint to communicate with and provide information related to my complaint to the Health Care Section. I verify that I have read and understand the informational sheet about this process and that the information provided is true and correct to the best of my knowledge, information and belief. PRINT YOUR NAME YOUR SIGNATURE DATE American LegalNet, Inc. www.FormsWorkFlow.com JOSH SHAPIRO ATTORNEY GENERAL healthcare@attorneygeneral.gov www.attorneygeneral.gov Health Care Complaint Form Health Care Section th 14 Floor, Strawberry Square Harrisburg, PA 17120 1-877-888-4877 1-717-705-6938 1-717-787-1190 (fax) WHEN SHOULD YOU FILE A COMPLAINT? If you are unable to resolve a health-related complaint directly with the person or company you are complaining against, then you should file a complaint with the Office of Attorney General, Health Care Section (HCS), by completing a complaint form and medical release authorization. If your complaint is against your insurance company, then you should refer to your contract to ensure that you have taken all the appropriate steps to file a complaint or grievance directly with the Plan. Filing a complaint with the HCS does not preserve your appeal rights; therefore, you are encouraged to file an appeal with your insurance company while simultaneously filing a complaint with the HCS. The completed forms and any supporting documentation should be mailed to the address below,