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All fields are required, unless labeled as (optional).

Section 1 - Beneficiary's Information

Are you submitting this form for yourself, or on behalf of someone else? Self Someone else

SUBMITTER'S INFORMATION

Submitter's first name Submitter's last name Submitter's phone number Submitter's relationship to the beneficiary

First name Last name Medicaid ID number Date of birth Email address Phone number Street address City State Zip code

Section 2 - Complaint Type

MEDICAID COVERED SERVICES

Is there a problem getting Medicaid covered services? Yes No

Examples: Medications, Medical Supplies, Behavioral Health assistance, Transportation, Dental. Please include all doctor or pharmacy names and phone numbers.

BILLING RELATED ISSUES

Is there a billing related issue? Yes No

Please do not send collection agency notices. Attached copies should have the provider's name, the provider's phone number, account number and date of service.

FILL UPLOAD

The size of each file must be less than 10 MB. Only two (2) files may be uploaded.

File 1 (optional) File 2 (optional)

Section 3 - Complaint Details

Provide detailed information about your complaint and anything you have done to attempt to solve the problem. Be as specific as possible.

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