Medicare Beneficiary Complaint Form

Date:04/17/2014
MEDICARE BENEFICIARY INFORMATION
First Name: Middle Name: Last Name:
Prefix: County:
Address Line 1: Address Line2:
City: State: 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 :
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: 04/17/2014