ONLINE FORM INSTRUCTIONS - PROVIDER COMPLAINT FORM
- Fill out the Complaint Form HERE. When your information is complete; click the "Submit" button.
- You will receive a "Complaint Confirmation" page. Please print out two (2) copies of the "Complaint Confirmation" page - one for your records and one to send to us.
The "Complaint Confirmation" contains the information you provided along with other important information about how we will handle the complaint.
- Send the following documents to our office via mail, email or fax:
- The "Complaint Confirmation" page
- 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.
- 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.
Office of the Attorney General, Health Education and Advocacy Unit
200 St. Paul Place, 16th Floor
Baltimore, MD 21202
FAX (410) 576-6571
Toll-free in Maryland
Receipt of the "Complaint Confirmation," the Authorization for Release of Medical Information and copies of other documents relevant to your complaint are necessary to begin the mediation process.
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.