Medicare Beneficiary Complaint Form
Instructions to fill out the form.
Fields with bold labels are required fields. Example - Medicare Claim Number on this form is a required field.
When you are done filling out this form, click the "Continue.." button.
On the "File Upload" page you will have the option to upload any forms that are needed to process your complaint.
After you are done uploading your forms, click the "Submit" button.
On the final "Form Submit" page you will have the opportunity to print the form.
YOU MUST CLICK
"SUBMIT"
OR YOUR FORM WILL NOT BE REVIEWED.
Date:04/25/2018
MEDICARE BENEFICIARY INFORMATION
First Name:
Middle Name:
Last Name:
Prefix:
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
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:
Home Phone:
Work Phone:
Work Phone Ext:
Cell:
Email:
Date of Birth:
Medicare Claim Number:
Effective Dates of Medicare -
Part A:
Part B:
INSURANCE INFORMATION
Plan Name:
Plan Member ID Number:
Agent First Name:
Agent Last Name:
Agent Phone:
Extra Help Or LIS Eligible Indicator:
Yes
No
Medicaid Eligible Indicator:
Yes
No
Type of Coverage:
Medicare Prescription Drug Plan
Medicare Advantage Plan
Other/Original Medicare
If someone other than the beneficiary is submitting the complaint, please provide your name, relationship to beneficiary and contact telephone number.
If you enter any field in 'Other than Beneficiary section', the other fields in this section are required.
First Name:
Last Name:
Relationship :
Attorney
Authorized Representative
Beneficiary
Medical Provider
Other
Other Driver
Parent
Passenger
Self
Self
Spouse
Phone:
DETAILS OF THE COMPLAINT:
The Seniors’ Health Insurance Information Program is authorized to send a copy of this document(s) to any company or agency (Federal or State) involved. I authorize the release of all relevant information to the Seniors’ Health Insurance Information Program NC Department of Insurance for its use in the review of this matter. Please note that consumer complaints become public records in accordance with North Carolina General Statute 58-2-100.
Date: 04/25/2018