Health Care Bureau Complaint Form - New York State Attorney General Page 2
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1
2Briefly describe your complaint (please attach extra pages if necessary):
Did someone refer you to this office?
Yes
No
If so, who?
Read the following before signing below.
PLEASE attach PHOTOCOPIES of your HEALTH PLAN IDENTIFICATION CARD (both sides), as well
as any relevant documents, such as the Explanation of Benefits (EOB) from your health plan, denials
of service, bills, correspondence, relevant sections of your subscriber contract or member handbook, etc.
DO NOT SEND ORIGINALS
L
NOTE: In order to resolve your complaint we may send a copy of this form to the individual
or company about whom you are complaining.
In filing this complaint, I understand that the Attorney General is not my private attorney, but represents the public.
I also understand that if I have any questions concerning my legal rights or responsibilities, I should contact a
private attorney. I have no objection to the contents of this complaint being forwarded to the individual or company
the complaint is directed towards, or to another agency if my complaint is referred to that agency. The above
complaint is true and accurate to the best of my knowledge.
I also understand that any false statements made in this complaint are punishable as a Class A Misdemeanor
under § 175.30 and/or § 210.34 of the Penal Law.
Signature ____________________________________ Date: ______________
º
Remember to enclose COPIES of any documentation with regard to this complaint.
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Mail to:
NYS Office of the Attorney General
Health Care Bureau
The Capitol
Albany, NY 12224-0341
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