INSTRUCTIONS

1. Print the Authorization for Release of Medical Information NOTE: We need this release form in order to proceed.

2. Select the form to use in filing your complaint over the Internet. See "Pick Your Complaint Form" below.

3. Fill out the form, then verify the information in your form. Edit any incorrect information. When your information is correct, click on the "Submit" button.

4. Print 2 copies of the “Complaint Confirmation” page - one for your records and one to mail in to us.

(The "Complaint Confirmation" contains the information you provided along with other important information about how we will handle your complaint.)

5. Mail to our office:

Receipt of the “Complaint Confirmation,” the Medical Record Consent form and copies of other documents relevant to your complaint are necessary to begin the mediation process.

PICK YOUR COMPLAINT FORM

• If your complaint involves a health care provider (such as a doctor or dentist), durable medical goods or equipment, drugs, or any other health care products, but does NOT involve your health insurance plan, click here.

• If your complaint involves a medical or pharmacy discount card, but does NOT involve your health insurance plan, click here.

• If your complaint involves a dispute with your health insurance plan or carrier, including a failure to pay your medical bills, a refusal to cover recommended services, an overcharge of your premiums or co-pays, or any other matter, click here.