Complaint Form
Is this a Medicare Complaint?
*
Yes
No
Is there an Appeal Element
*
Yes
No
Is this complaint related to a prescription drug?
*
Yes
No
Member Name
*
First
Last
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
*
Parent
Legal Guardian
Spouce
Other
If Other - Relationship to Member
Complaintant Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Complaint Type
*
Accessibility/Availability of Service - Geographic Access
Accessibility/Availability of Service - Appointment Availability
Attitude and Service Health Plan
Balance Billing
Complaint Process
Marketing
Pharmacy
Plan Administration - ID Cards
Plan Administration - Language or Interpreter Services
Plan Administration - Miscellaneous
Quality of Care
Quality of Service - Office Site - Miscellaneous
Quality of Service - Office Site - Physical Appearance
Quality of Service - Office Site - Adequacy of Wait TIme
Quality of Service - Practitioner
Transportation
Other
Other Complaint Type
Form Completed by:
*
Member
Member's Representative
SHP Staff
Name of Person Completing Form
*
First
Last
How can Superior resolve your issue?
*
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