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SHARE YOUR CONCERN / ISSUE
INSURANCE ISSUE/CONCERN
Use this form to submit your insurance issue/concern.
Please enter your name (required):
Please enter your practice name:
E-mail address:
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Insurance Company/Plan:
Please briefly describe your issue/concern:
What steps have you taken to resolve this issue?
Have spoken with the patient?
Yes
No
Have contacted the insurance company representative?
Yes
No
Have contacted the Insurance Commisioner
Yes
No
Have filed complaint with Attorney General
Yes
No
What response or resolution did you receive?: