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Independent Health Care Provider Complaint Form

All fields with * are required fields. You cannot submit your report until all required fields are completed.

PROVIDER INFORMATION

Practitioner's Name:*

Title

First*

Middle

Last*

Name and Type of Practice:*

Is this an individual or group practice?*

Individual

Group

If group, how many providers?*

Is the practice/practitioner affiliated with a hospital or larger provider group?*

Yes

If Yes, provide the name, address and contact for the group:

Name

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Person Filing Complaint (if different than provider):

Title

First*

Middle

Last*

Mailing Address:

Address*

City/Town*

State/Province*

ZIP/Postal Code*

Email:*

Telephone Numbers:

Work/Office*

Mobile:

INSURANCE COMPANY INFORMATION

Name*

Address

City/Town

State/Province

ZIP/Postal Code

Telephone Number:

Provider Contract Number:

Details of Your Complaint:

*Tell us what happened, who is involved, what the issues are, what you have done to resolve the issues and the name of anyone at the Maine Bureau of Insurance you have talked to about your complaint.

Provider Authorization

I hereby authorize the Maine Bureau of Insurance to investigate my complaint. This authorization remains in effect 12 months from the date the authorization is signed or until I revoke it in writing. Your signature below confirms that all consumers have been notified if their claims are involved in any provider complaint and the outcome could affect their coverage.

Completed By:*

Email:*

Date*

Maine.gov

Independent Health Care Provider Complaint Form