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Please complete the entire form.
Please do not include Social Security Numbers.
Complaint Type: No Pay Late Pay Coding Other:
Complaint is Against: Insurer Third Party Administrator
PLEASE SUPPLY ALL COMPLETE NAMES AS LISTED ON THE INSURANCE CARD.
Claim was filed: On Paper ElectronicallyAmount of claim(s):
Was Claim Clean: Yes No If no, what additional information was requested:
Date of additional information being requested:
Date information was provided:
Partial payment received: Yes Amount Reason given for this amount: No
Dates of attempts to collect payment:
Please include a brief summary of the reason for the complaint, and any additional information you believe will be helpful to the review of your complaint:
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