Beneficiary Complaint Form (BCF)

All fields are required unless labeled as optional.

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Beneficiary Name Medicaid ID Number Date of Birth Beneficiary Address (Number and Street) City State Zip Code Email Address Beneficiary Telephone Number

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Complaint Type Billing Issues – Attach copies of bill(s). Do not send collection agency notices. Please include Provider Name, Provider Phone Number, Account Number and Date of Service. Problem Getting Medicaid Covered Services (ie. Medications, Medical Supplies, Behavioral Health assistance, Transportation, Dental) Please include all doctor or pharmacy names and phone numbers.

Attach copies of the bill(s). Do not send copies of collections notices. (Maximum of 2 files, 10MB file size each)

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Provide detailed information about your complaint and anything you have done to solve the problem. Be as specific as possible and attach additional pages if needed.

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Beneficiary Complaint Form (BCF)

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