Complaint Form
Member First Name (required)
Member Last Name (required)
Member Medicaid or CHIP ID Number (required)
Complaintant Email Address
Complaintant Phone Number
Member County
Provider
Complaint Summary (required)
Member Date of Birth
Complaintant Relationship to Member (required)
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Parent
Legal Guardian
Spouse
Other
If Other - Relationship to Member
Complaintant Street Address (required)
Complaintant City (required)
Complaintant State (required)
Complaintant Zip (required)
Complaint Type (required)
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Accessibility/Availability of Service - Geographic Access
Accessibility/Availability of Service - Appointment Availability
Attitude and Service Health Plan
Balance Billing
Complaint Process
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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 (required)
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Member
Member's Representative
SHP Staff
Name of Person Completing Form (required)
How can Superior resolve your issue? (required)
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