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You must submit, in writing, comments, documents, records or other information relevant to the complaint/grievance If requested. If you have a comment or complaint about your benefit plan design or any restrictions, please contact your health plan sponsor.

 

Please complete the form below

Member/Provider Name *
Member/Provider Name
Date of Occurrence
Date of Occurrence
Date of Birth
Date of Birth
Address
Address
Phone
Phone
Submitter's Name
Submitter's Name
Submitter's Phone
Submitter's Phone
Please state all details relating to the matter in question, including names, Rx Numbers, dates, places, etc.
What steps were taken?
Requester Name
Requester Name
Requester Phone Number
Requester Phone Number