Complaint Form » Fostercare Texas

Is this a Medicare Complaint?*

Is there an Appeal Element*

Is this complaint related to a prescription drug?*

Member Name*

FirstLast

Member Medicaid or CHIP ID Number*

Complaintant Email Address

Complaintant Phone Number

Member County

Provider

Complaint Summary*

Member Date of Birth

Complaintant Relationship to Member*

If Other - Relationship to Member

Complaintant Address*

Street AddressCityStateZip Code

Complaint Type*

Other Complaint Type

Form Completed by:*

Name of Person Completing Form*

FirstLast

How can Superior resolve your issue?*