ATTORNEY 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)