Request for Assistance Form

Date: 05/22/2017
COMPLAINANT INFORMATION
Prefix: First Name: Middle Initial: Last Name:
Business: County:
Address Line 1: Address Line2:
City: State: Zip Code:
Work Phone: Work Phone Ext: Home Phone:
Cell: Fax: Email:
Relationship to the Insured:
INSURANCE INFORMATION
Name of Insured if different - First Name: Middle Initial Last Name:
Insurance Company:
Agent:
Adjuster:
Policy or Subscriber ID#:
Claim or Certificate #:
Date of Loss(mm/dd/yyyy):
Type of Insurance(Please select one) Life Health Auto Homeowners Other Life/Health Other Property/Casualty
If Life or Health policy, show the state in which your policy/certificate was purchased:
Are you represented by an attorney in this matter? Yes No
(If yes, please provide the consent form)
Attorney Name:
Are you covered under the North Carolina state health plan? Yes No
Are you covered under a self-funded employer plan? Yes No
Are you requesting assistance with filing a medical appeal for denied medical services? Yes No
Information on Doctor or Provider Who is Performing or Recommending the Service(If Applicable)
The North Carolina Department provides a service to consumers who have been denied medical services by their health insurance company. The staff will assist you with constructing your appeal and submitting it to the insurance company. In order to assist you with this, it is necessary for us to obtain some additional information as well as your written consent to obtain your medical records if it is necessary. If you answered yes to any of the last three questions, please include the following information about the medical provider:
Title: First Name: Middle Name:
Last Name:
Practice:
Address:
City: State: Zip Code:
Work Phone: Ext: Fax Phone:
DETAILS OF THE COMPLAINT(4000 Character Maximum):
Characters Remaining:4000
How did you hear about us?
Authorization Release
Insurance Department is authorized to send a copy of this document(s) to any company or agency involved. I authorize the release of all relevant information to the North Carolina Department of Insurance for its use in the review of this matter. Please note that consumer complaints become public records in accordance with applicable laws.
Medical Authorization Release
The undersigned has requested assistance from the North Carolina Department of Insurance(Department) with a medical appeal. In order to facilitate this assistance, the undersigned authorizes the Department to obtain from the health plan or health Insurance issuer involved, and their sub-contractors, all information relating to the matter 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 sole responsibility of the undersigned. 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. As provided by applicable laws, all patient medical records in the possession of the Department shall be confidential.
Date: 05/22/2017