Contact Information

Please provide your basic contact information in case we need to follow up on your complaint.

Middle Name Address Line Two Phone Number

Insurance Information

I am the insured person associated with this complaint.
I am not the insured person associated with this complaint.
I am a healthcare provider submitting this complaint on behalf of a patient.

Group Number Policy Number Claim Number Level of Coverage Sublevel of Coverage Check here if an agent/broker was involved with this complaint. Agent Address Line 1 Agent Address Line 2 Agent City Agent State Agent Zip Code Agent Email Address Agent Phone Number

Complaint Description

Incident Date Incident Date (!)

Please provide as many details as possible regarding your complaint.

Please describe your expected resolution for your complaint.

Complaint Reasons

Reason for Complaint - Select up to three (3) items

Supporting Documentation

If you have any supporting documentation, please attach it below.

Public Records

This complaint form, all documents you send us, and any document received by our office as a result of handling your complaint may be a public record, subject to Ohio's Public Records Act. This law requires all public records to be available for inspection by anyone, upon request.

Supporting Document One Supporting Document Two Supporting Document Three

Submit Complaint

To the best of my knowledge the above statement is correct. I understand that a copy of this form and any attachments may be sent to the insurance company or agent involved. I authorize the insurance company to release all of the medical records relating to this complaint to the Ohio Department of Insurance and I authorize the Ohio Department of Insurance to release medical records relating to this complaint to the insurance company or agent as necessary in order to resolve this complaint. I represent that I have the proper authority to execute this release.

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Submitting Complaint

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Ohio Department of Insurance

50 West Town Street

Third Floor - Suite 300

Columbus OH 43215

Consumers 800-686-1526 | Medicare 800-686-1578 | Fraud & Enforcement 800-686-1527