Instructions for Providers to File a Complaint by Mail

1. Gather any documents that are relevant to the complaint. Examples include:

• a copy of the claim your office submitted to the health insurance carrier
• an adverse coverage decision from the carrier;
• a copy of the Medical Authorization Form signed by the patient (if any);
• billing statements; and,
• correspondence.

(You may need to refer to these documents while you are filling out the complaint form and will need to send copies of these documents to our office after you file your complaint.)

2. Download the provider complaint form.

(If you are unable to download or print the complaint form, call our office to have one mailed to you: 410-528-1840 or toll-free in Maryland: 1-877-261-8807.)

3. Fill out the form on the computer, then print it; or print it out to complete by hand.

4. Mail to our office:

• The filled out complaint form;
• A completed Medical Record Consent;
• Copies of any documents that are relevant to your complaint. (NOTE: Please do not send original documents.)

6. Keep a copy of the complaint for your records.

Receipt of the Medical Authorization Form and copies of other documents relevant to your complaint are necessary to begin the mediation process.

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.