Request for Assistance Form
INSTRUCTIONS
For this page to function it is necessary to enable JavaScript.
Here are the instructions for enabling JavaScript in your web browser
Fill out the requested information.
Fields with bold labels are required fields.
Example -
First Name
is a required field on this form.
Use your mouse to sign the form in the designated spots. Both signatures are required.
When you are done click the "Continue" button.
On the next page you will have the option to upload any forms that are needed to process your Request for Assistance.
You may print the form from this page or from the last page.
After you are done uploading your forms, click the "Submit" button.
YOU MUST CLICK
"SUBMIT"
OR YOUR FORM WILL NOT BE REVIEWED.
Date: 03/05/2021
Title:
First Name:
Middle Name:
Last Name:
Address Line 1:
Address Line2:
City:
State:
Alabama
Alaska
Alberta, Canada
Arizona
Arkansas
Bermuda
British Columbia, Canada
California
Canada
Cayman Islands, BWI
Colorado
Connecticut
Delaware
Denmark
District of Columbia
England
Finland
Florida
France
Georgia
Germany
Hawaii
Idaho
Illinois
Indiana
Iowa
Italy
Kansas
Kentucky
Louisiana
Maine
Manitoba, Canada
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick, Canada
New Hampshire
New Jersey
New Mexico
New York
New Zealand
Newfoundland, Canada
North Carolina
North Dakota
Northwest Territories, Canada
Nova Scotia, Canada
Nunavut, Canada
Ohio
Oklahoma
Ontario, Canada
Oregon
Pennsylvania
Prince Edward Island, Canada
Puerto Rico
Quebec, Canada
Rhode Island
Saskatchewan, Canada
Scottland
South Carolina
South Dakota
Spain
Sweden
Tennessee
Texas
United Kingdom
Utah
Vermont
Virgin Islands
Virginia
Wales, Great Britain
Washington
West Virginia
Wisconsin
Wyoming
Yukon, Canada
Zip Code:
County:
Alamance
Alexander
Alleghany
Anson
Ashe
Avery
Beaufort
Bertie
Bladen
Brunswick
Buncombe
Burke
Cabarrus
Caldwell
Camden
Carteret
Caswell
Catawba
Chatham
Cherokee
Chowan
Clay
Cleveland
Columbus
Craven
Cumberland
Currituck
Dare
Davidson
Davie
Duplin
Durham
Edgcombe
Forsyth
Franklin
Gaston
Gates
Graham
Granville
Greene
Guilford
Halifax
Harnett
Haywood
Henderson
Hertford
Hoke
Hyde
Iredell
Jackson
Johnston
Jones
Lee
Lenoir
Lincoln
Macon
Madison
Martin
McDowell
Mecklenburg
Mitchell
Montgomery
Moore
Nash
New Hanover
Northhampton
OUT-OF-STATE
Onslow
Orange
Pamlico
Pasquotank
Pender
Perquimans
Person
Pitt
Polk
Randolph
Richmond
Robeson
Rockingham
Rowan
Rutherford
Sampson
Scottland
Stanly
Stokes
Surry
Swain
Transylvania
Tyrell
Union
Vance
Wake
Warren
Washington
Watauga
Wayne
Wilkes
Wilson
Yadkin
Yancey
Home Phone:
Work Phone:
Ext:
Cell:
Fax:
Email:
Gender:
M
F
Ethnicity:
Asian American
Black
Hispanic
Indian/Native American
Other
Refused to Answer
Unknown Race
White
Date of Birth:
(mm/dd/yyyy)
PROBLEM: UNINSURED or LOSING INSURANCE IN THE NEAR FUTURE
I have no insurance / I am going to lose my insurance / I need help finding insurance coverage option.
Marital Status:
Divorced
Domestic Partner
Married
Not applicable (child)
Separated
Single
Unknown
Widowed
Employment Status:
Full Time, More than one job
Full Time, One job
Not working, Disabled
On Leave
Part-Time
Retired
Self-Employed: No Employees
Self-Employed: Non-Spouse Employee(s)
Self-Employed: Spouse Only Employee
Unemployed, Looking for work
Unemployed, Not looking for work
Unknown Employment Status
Monthly Income Level:
Health Conditions:
I had insurance but the company rescinded (cancelled) the coverage.
Name of Insurer:
PROBLEM: INSURED BUT HAVING TROUBLE WITH INSURER
I have insurance but received a denial for medical treatment or services.
I am requesting assistance with the appeal process.
I have insurance but having trouble with other issues.
Claim processing Complaint.
Out of Network Claim Complaint.
Pre-existing condition exclusion problem.
Dependent coverage to age 26 problem.
Preventive services cost sharing problem.
Pre-existing condition denial complaint.
Annual or lifetime benefit limit problem.
Coordination of Benefits.
Medical loss ratio rebate problem.
Out of network emergency care denial complaint.
Choice of PCP/Pediatrician problem.
Other:
I want to file a complaint to my insurer about the problem I checked above and would like your help.
PROBLEM: INFORMATION
I need information about an insurance issue I am having.
Nature of Issue:
Who else may we communicate with regarding this issue:
1) Title:
First Name:
Middle Name:
Last Name:
Address Line 1:
Address Line 2:
City:
State:
Alabama
Alaska
Alberta, Canada
Arizona
Arkansas
Bermuda
British Columbia, Canada
California
Canada
Cayman Islands, BWI
Colorado
Connecticut
Delaware
Denmark
District of Columbia
England
Finland
Florida
France
Georgia
Germany
Hawaii
Idaho
Illinois
Indiana
Iowa
Italy
Kansas
Kentucky
Louisiana
Maine
Manitoba, Canada
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick, Canada
New Hampshire
New Jersey
New Mexico
New York
New Zealand
Newfoundland, Canada
North Carolina
North Dakota
Northwest Territories, Canada
Nova Scotia, Canada
Nunavut, Canada
Ohio
Oklahoma
Ontario, Canada
Oregon
Pennsylvania
Prince Edward Island, Canada
Puerto Rico
Quebec, Canada
Rhode Island
Saskatchewan, Canada
Scottland
South Carolina
South Dakota
Spain
Sweden
Tennessee
Texas
United Kingdom
Utah
Vermont
Virgin Islands
Virginia
Wales, Great Britain
Washington
West Virginia
Wisconsin
Wyoming
Yukon, Canada
Zip Code:
Phone:
Phone Ext:
2) Title:
First Name:
Middle Name:
Last Name:
Address Line 1:
Address Line 2:
City:
State:
Alabama
Alaska
Alberta, Canada
Arizona
Arkansas
Bermuda
British Columbia, Canada
California
Canada
Cayman Islands, BWI
Colorado
Connecticut
Delaware
Denmark
District of Columbia
England
Finland
Florida
France
Georgia
Germany
Hawaii
Idaho
Illinois
Indiana
Iowa
Italy
Kansas
Kentucky
Louisiana
Maine
Manitoba, Canada
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick, Canada
New Hampshire
New Jersey
New Mexico
New York
New Zealand
Newfoundland, Canada
North Carolina
North Dakota
Northwest Territories, Canada
Nova Scotia, Canada
Nunavut, Canada
Ohio
Oklahoma
Ontario, Canada
Oregon
Pennsylvania
Prince Edward Island, Canada
Puerto Rico
Quebec, Canada
Rhode Island
Saskatchewan, Canada
Scottland
South Carolina
South Dakota
Spain
Sweden
Tennessee
Texas
United Kingdom
Utah
Vermont
Virgin Islands
Virginia
Wales, Great Britain
Washington
West Virginia
Wisconsin
Wyoming
Yukon, Canada
Zip Code:
Phone:
Phone Ext:
Insurance Information:
Insurance Company Name as it Appears on card:
PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD
Name of the Policy Holder:
Member ID:
Group Number:
Name of your employer:
Spouse's Employer:
Spouse's Insurer:
Information on Treating Physician #1:
Title:
First Name:
Middle Name:
Last Name:
Practice:
Address:
City:
State:
Alabama
Alaska
Alberta, Canada
Arizona
Arkansas
Bermuda
British Columbia, Canada
California
Canada
Cayman Islands, BWI
Colorado
Connecticut
Delaware
Denmark
District of Columbia
England
Finland
Florida
France
Georgia
Germany
Hawaii
Idaho
Illinois
Indiana
Iowa
Italy
Kansas
Kentucky
Louisiana
Maine
Manitoba, Canada
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick, Canada
New Hampshire
New Jersey
New Mexico
New York
New Zealand
Newfoundland, Canada
North Carolina
North Dakota
Northwest Territories, Canada
Nova Scotia, Canada
Nunavut, Canada
Ohio
Oklahoma
Ontario, Canada
Oregon
Pennsylvania
Prince Edward Island, Canada
Puerto Rico
Quebec, Canada
Rhode Island
Saskatchewan, Canada
Scottland
South Carolina
South Dakota
Spain
Sweden
Tennessee
Texas
United Kingdom
Utah
Vermont
Virgin Islands
Virginia
Wales, Great Britain
Washington
West Virginia
Wisconsin
Wyoming
Yukon, Canada
Zip Code:
Work Phone:
Ext:
Fax Phone:
Information on Treating Physician #2:
Title:
First Name:
Middle Name:
Last Name:
Practice:
Address:
City:
State:
Alabama
Alaska
Alberta, Canada
Arizona
Arkansas
Bermuda
British Columbia, Canada
California
Canada
Cayman Islands, BWI
Colorado
Connecticut
Delaware
Denmark
District of Columbia
England
Finland
Florida
France
Georgia
Germany
Hawaii
Idaho
Illinois
Indiana
Iowa
Italy
Kansas
Kentucky
Louisiana
Maine
Manitoba, Canada
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick, Canada
New Hampshire
New Jersey
New Mexico
New York
New Zealand
Newfoundland, Canada
North Carolina
North Dakota
Northwest Territories, Canada
Nova Scotia, Canada
Nunavut, Canada
Ohio
Oklahoma
Ontario, Canada
Oregon
Pennsylvania
Prince Edward Island, Canada
Puerto Rico
Quebec, Canada
Rhode Island
Saskatchewan, Canada
Scottland
South Carolina
South Dakota
Spain
Sweden
Tennessee
Texas
United Kingdom
Utah
Vermont
Virgin Islands
Virginia
Wales, Great Britain
Washington
West Virginia
Wisconsin
Wyoming
Yukon, Canada
Zip Code:
Work Phone:
Ext:
Fax Phone:
DETAILS OF THE COMPLAINT:
PROVIDE/ATTACH ANY DOCUMENTATION THAT IS IMPORTANT OR PERTAINS TO THIS COMPLAINT SUCH AS
THE DENIAL FROM YOUR INSURER OR LETTERS FROM YOUR TREATING PHYSICIAN.
IMPORTANT: Consent Form for Health Insurance Smart NC To Assist me with my appeal/complaint.
The undersigned individual has requested assistance from Health Insurance Smart NC, (a division of the North Carolina Department of Insurance) as provided pursuant to Sec. 2793 of Part C of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-91 et seq.) and consents to the provision of this assistance by Health Insurance Smart NC and its agents or employees. The undersigned consents to the use of a translation service, at the expense of Smart NC, which shall treat the provided information as confidential, to translate any contents of this document that are submitted in a language other than English. The undersigned acknowledges that the information and assistance provided by Health Insurance Smart NC does
not
constitute legal representation and that Health Insurance Smart NC may
not
serve as the undersigned's authorized representative in any hearing or in any other capacity.
The undersigned acknowledges that there shall be no liability on the part of, and no cause of action of any nature shall arise against, Health Insurance Smart NC or its agents or employees, the North Carolina Department of Insurance ("NCDOI") or its agents or employees, or the Commissioner or the Commissioner's representatives for any action taken by them in good faith in the performance of their powers and duties.
Type Name Here:
Date: 03/05/2021
IMPORTANT: Release of your medical information
The undersigned individual has requested assistance from Health Insurance Smart NC, a division of the North Carolina Department of Insurance. In order to facilitate this assistance, the undersigned authorizes Health Insurance Smart NC to obtain from the health insurance plan or health insurance issuer involved, and their sub-contractors, all information relating to the matter in question, including, but not limited to, the individual's files and medical record information. Payment of fees, if any, for obtaining these records is the responsibility of the undersigned. As provided by NCGS 58-2-105, all patient medical records in the possession of NCDOI and Health Assurance Smart NC shall be confidential.
This authorization will automatically expire upon final resolution of the matter giving rise to the undersigned's request for Health Insurance Smart NC assistance. The undersigned may revoke this authorization at any time. Revocation of this authorization will be effective upon receipt, but will not affect actions already taken on the basis of this authorization.
Type Name Here:
Date: 03/05/2021