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Provider Online Filing Form

Patient Information Sheet

Medical Authorization Form

Download a PROVIDER COMPLAINT FORM here to file by mail.

Health Education and Advocacy Unit
Mon-Fri 9 am-4:30 pm (410) 528-1840
FAX (410) 576-6571
To appeal health plan claims decisions:
Toll-free in Maryland
1-877-261-8807

You will need Acrobat Reader to download the form. Click here to download Acrobat Reader if you do not have it on your computer.

   

COMPLAINTS BEING FILED BY PROVIDERS

Providers may file a complaint on behalf of a consumer if the consumer authorizes the provider to do so.

Providers can file a complaint by mail by filling out a provider complaint form and mailing it to the following address or faxing it to (410) 576-6571:

Office of the Attorney General
Consumer Protection Division
Health Education and Advocacy Unit
200 Saint Paul Place, 16th Floor
Baltimore, Maryland 21202-2021

Providers should include copies of all relevant documents, including a copy of the claim the provider's office submitted to the health insurance carrier, an adverse coverage decision from the carrier, billing statements, and correspondence.

To file a complaint online, fill out the online provider complaint form, and forward all relevant documents by mail.

If possible, providers should include a copy of the Authorization for the Release of Medical Information signed by the patient with the complaint. If we do not receive the Authorization with the complaint, we will contact your patient to obtain the Authorization for the Release of Medical Information.

Regardless of how you submit the complaint on behalf of the consumer, we cannot begin assisting in the insurance dispute until we receive a completed Authorization for the Release of Medical Information form signed by the consumer.

Privacy Note: The information you submit will be used by the Attorney General staff in investigating your complaint. Medical or psychological information about an individual will not be disclosed to the public. To read our full privacy policy, click here.

 

 

Attorney General of Maryland 1 (888) 743-0023 toll-free / TDD: (410) 576-6372
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