Complaint Form Page 2

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WHAT DO YOU FEEL IS A FAIR RESOLUTION TO THIS COMPLAINT_______________________________
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“I authorize (Insurance Company Name) ____________________________________________________________) to
release all medical records, including nonpublic personal health information and nonpublic personal financial information,
which are related to this complaint, to the Office of Superintendent of Insurance. I authorize the release of such information,
as necessary for the investigation, evaluation and resolution of my complaint, as allowed by law and on a need-to-know
basis. I understand that my health insurer protects such information from unauthorized disclosure under federal and state law
and other Office of Superintendent of Insurance rules and regulations. I understand that the Office of Superintendent of
Insurance does not act as an attorney for private citizens.”
Complainant’s Signature __________________________________________________Date _______________________
1 888 4ASK OSI

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