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IDOI > Consumer Services > Complaints > Provider Complaint Form Provider Complaint Form

Please complete the entire form.

Please do not include Social Security Numbers.

Provider's Name:
Provider's Address:
City:
County:
Zip Code:
Contact Person:
Title:
Specialty:
Phone:
Fax:
Email:

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.

Insurer/TPA Name:
Insurer/TPA Address:
City:
State:
Zip Code:
Network Name:
Name of Employer:
Name of Insured:
Group ID Number:
Member ID Number:
Name of Patient:
Relationship to Insured:
Patient's Address:
City:
Zip Code:
Phone Number:
Date of Service:
Dates of claim filing:

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: