STATE OF MISSOURI



STATE OF MISSOURI

DEPARTMENT OF INSURANCE, FINANCIAL INSTITUTIONS & PROFESSIONAL REGISTRATION

CONSUMER AFFAIRS DIVISION

PROVIDER COMPLAINT FORM/RELATED TO PROMPT PAYMENT OF HEALTH CLAIMS

INSTRUCTIONS

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PLEASE PRINT, TYPE OR WRITE CLEARLY IN BLACK OR BLUE INK

|1. Name of Provider |

|Tax ID Number |

|Complete Mailing Address |

|Telephone Number |

|2. Name of Insured |

|Complete Mailing Address |

|3. Who is Complaint Against (Name of TPA or HMO) |

|Complete Mailing Address |

|Group # Policy # Date of Issue |

|ID # Certificate # Date of Issue |

|Claim # Date of Loss |

|Type of Coverage |

|□ Individual Health □Group Health □ Med Supplement □ Other |

|Details of Complaint |

| |

| |

| |

| |

| |

| |

| |

| |

|SIGNATURE OF COMPLAINTANT |

|DATE |

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PLEASE COMPLETE ALL ITEMS BELOW AND ENCLOSE COPIES OF ANY CORRESPONDENCE OR OTHER PAPERS WHICH YOU FEEL W؀࡝࡞࡯ࡸ࢏ࢼࢽࣉ࣊࣋࣢ࣣࣦࣤࣥठఀంఴశౚౠಆಈಘಚಜ뫆ꎱꎱ肑놣歷卟卟卟䝟wᔗ㩨ήᘀ쵨虬㔀脈䩃䩡ᔗ㩨ήᘀ㩨ή㔀脈䩃(䩡(ᔗ㩨ήᘀ㩨ή㔀脈䩃䩡ᔗ㩨ήᘀ쵨虬㔀脈䩃(䩡(ᘑ쵨虬㔀脈䩃䩡̠jᔀ㙨⵺ᘀ쵨虬㔀脈䩃ࡕ愁ᙊ̢jᘀ㙨⵺OULD HELP THE INVESTIGATION OF YOUR COMPLAINT. SIGN AND DATE AT THE BOTTOM. A COPY OF THIS FORM AND ANY OR ALL OF THE ENCLOSED INFORMATION MAY BE SENT TO THE PARTY COMPLAINED AGAINST. SEND COMPLETED FORM ALONG WITH ANY ATTACHMENTS TO:

MISSOURI DEPARTMENT OF INSURANCE,

FINANCIAL INSTITUTIONS & PROFESSIONAL REGISTRATION

INSURANCE MARKET REGULATION DIVISION

PO BOX 690

JEFFERSON CITY, MO 65102-0690

(573) 751-2640

(800) 726-7390

(573) 526-4536 TDD

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