Health Care Bureau Complaint Form - New York State Attorney General
Download a blank fillable Health Care Bureau Complaint Form - New York State Attorney General in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Health Care Bureau Complaint Form - New York State Attorney General with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2ATTORNEY GENERAL Eric T. Schneiderman
COMPLAINT FORM
State of New York
Office of the Attorney General
Consumer Hotline
For the Hearing Impaired
HEALTH CARE BUREAU
1-800-428-9071
TDD 1-800-651-7820
The Capitol
Albany, NY 12224-0341
Tel. (518) 474-8376 Fax (518) 402-2163
1. Please TYPE or PRINT clearly in DARK ink.
2. Make sure to enclose COPIES of important papers concerning this complaint.
CONSUMER Information
Name
Home Telephone #
Street Address
Work Telephone #
City/Town
County
State
Zip Code
COMPLAINT Information
Name of person or company you are complaining about:
Address
City/Town
State
Zip
Telephone #
Date(s) of Service
Cost of Service
How paid (check those that apply)
Name/Relation of Patient (if other than
$
Cash
Check
Credit Card
Other
self):
Name of Your Health Plan and Your Identification Number:
ID number for family member (if complaint involves family member):
Type of Health Plan
HMO
Preferred Provider Organization (PPO)
Point of Service plan (HMO-POS)
Indemnity
Medicare (traditional)
Medicare + Choice (HMO)
Medicaid
Medicaid HMO
Other __________________
No insurance
Don’t Know
Do you have insurance through your employer?
Yes
No
If yes, what is the name of your employer?
Date you complained to the individual or company:
By:
Mail
Telephone
in person
Person Contacted:
Job title:
Did you file a formal appeal or grievance with your health plan?
What was the response to the complaint or appeal?
Has the matter been submitted to another agency or attorney? [If yes, please provide name and address]
Yes
No
Has this matter gone to collections? [If yes, please provide name and address of collection agency]
Yes
No
Please describe the complaint on the reverse side.
HCB 001 (8/04)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Tt-102 - New York State Resident Affidavit Form - New York State Department Of Taxation And Finance - New York
Legal
Form Emedny-490301 - Application For Enrollment As A Specialist Form - New York State Department Of Health
Legal
Form St-101 - New York State And Local Annual Sales And Use Tax Return Form - New York State Department Of Taxation And Finance
Financial
Related Categories
Parent category: Legal