Managed Care Organization Complaint Form
Please use this form to submit a complaint about your experience with a managed care organization. Do not include sensitive health or financial details.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Managed Care Organization Name
*
Type of Complaint
*
Please Select
Access to Services
Customer Service
Billing or Charges
Coverage Dispute
Network Provider Issue
Quality of Care
Other
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location (if relevant)
Please describe your complaint in detail
*
What actions have you taken so far?
What resolution are you seeking?
Submit Complaint
Should be Empty: