New Jersey Department of Banking and Insurance
|New Jersey Department of Banking and Insurance |FOR STATE USE ONLY |
|Office of Managed Care | |
|PO Box 475 | |
|Trenton, NJ 08625-0475 | |
|Toll-Free Number: 1-888-393-1062 FAX: 609-777-0508 or 609-292-2431 | |
|COMPLAINT | |
|Instructions: Please print or type this entire form, and mail to | |
|the address listed above. The form must be signed and dated. | |
| |Date Rec'd |
| |File No |
| |Category |
| |Invest. |
|Name of Complainant |Type |
| |Consumer Provider |
|Name of Carrier |Member ID Number |
| | |
|Subscriber Name |Subscriber ID Number |
| | |
|Street Address of Complainant |Telephone Number (Home) |
| | |
|City County State Zip Code |Telephone Number (Business) |
| | |
|On Behalf Of (if same as above, write "SAME") |E-mail Address |
| | |
|Coverage is Through: |
|Work NJ Family Care Medicare Federal Government |
|Individual Medicaid NJ State Health Benefits |
|Details of Complaint (Include copies of documents and correspondence that you believe will assist us in our inquiry. Do not use the back of this form; |
|however, you may attach additional pages if necessary.) |
| |
| |
|Have you utilized the Carrier’s Internal Complaint/Grievance Appeal Process? Yes No |
|In order to assist the Department in our inquiry of your complaint, we request that you sign and date the following authorization for the release of |
|information: |
| |
|I understand that a copy of this form and any enclosures may be sent to the carrier named in the complaint and I authorize the release to the New Jersey |
|Department of Banking and Insurance any medical and/or administrative records pertinent to this complaint. |
|Signature of Complainant |Date |
| | |
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