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Complaint Report

Complete this online form or refer to this printable pdf.

Contact Information:
   

   
       
   

   


Please include dates of service, claim #s, dollar amounts, and provider's names.

Complaint Against Agent/Broker:


       

Information on Enrollment Issues:
       

These should include such things as agencies you have reported this to, calls you have made to try and resolve this, additional parties involved, etc. Also, please attach any documentation such as billing notices, Medicare Summary notices, or letters that support your complaint (for example: a dis-enrollment letter from an insurance company) that you feel would help us to resolve this complaint.

I understand that personal medical information related to my complaint may be disclosed to a SHIBA or SMP representative.


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