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 |
-----------------------
PLEASE COMPLETE ALL ITEMS BELOW AND ENCLOSE COPIES OF ANY CORRESPONDENCE OR OTHER PAPERS WHICH YOU FEEL W࡞ࡸࢼࢽࣉࣣࣦ࣊࣋ࣤࣥठఀంఴశౚౠಆಈಘಚಜ뫆ꎱꎱ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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