Request for Assistance Form

INSTRUCTIONS
Date: 02/17/2019
Title: First Name: Middle Name:
Last Name:
Address Line 1: Address Line2:
City: State: Zip Code:
County:
Home Phone: Work Phone: Ext:
Cell: Fax: Email:
Gender: M F Ethnicity:
Date of Birth:  (mm/dd/yyyy)
PROBLEM: UNINSURED or LOSING INSURANCE IN THE NEAR FUTURE
Marital Status:
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I had insurance but the company rescinded (cancelled) the coverage.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
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: Zip Code:
Phone: Phone Ext:
2) Title: First Name: Middle Name:
Last Name:
Address Line 1: Address Line 2:
City: State: 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: Zip Code:
Work Phone: Ext: Fax Phone:
Information on Treating Physician #2:
Title: First Name: Middle Name:
Last Name:
Practice:
Address:
City: State: 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.
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: 02/17/2019
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: 02/17/2019