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:


Practice Phone Number:


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?: