ࡱ> o Hbjbj 1P֘zf֘zf+ 555III8LIg,Yr#:$%`+++++++$.0B+]5'##"''+!,+++'j8++'++++Ќ?56(j++7,0g,+1(1+15+x&Zn&@+&4&&&&++H*&&&g,''''1&&&&&&&&& : New Jersey Department of Banking and Insurance Office of Managed Care PO Box 475 Trenton, Sexy 08625-0475 Toll-Free Number: 1-888-393-1062 FAX: 609-777-0508 or 609-292-2431 COMPLAINT Instructions: Please print or type this entire form, and mail to the address listed above. The form must be signed and dated. FOR STATE USE ONLYDate Rec'dFile NoCategoryInvest. Name of Complainant  FORMTEXT      Type  FORMCHECKBOX  Consumer  FORMCHECKBOX  ProviderName of Carrier  FORMTEXT      Member ID Number  FORMTEXT      Subscriber Name  FORMTEXT      Subscriber ID Number  FORMTEXT      Street Address of Complainant  FORMTEXT      Telephone Number (Home)  FORMTEXT      City County State Zip Code  FORMTEXT      Telephone Number (Business)  FORMTEXT      On Behalf Of (if same as above, write "SAME")  FORMTEXT      E-mail Address  FORMTEXT      Coverage is Through:  FORMCHECKBOX  Work  FORMCHECKBOX  Sexy Family Care  FORMCHECKBOX  Medicare  FORMCHECKBOX  Federal Government  FORMCHECKBOX  Individual  FORMCHECKBOX  Medicaid  FORMCHECKBOX  Sexy State Health Benefits Details of Complaint (Include copies of documents and correspondence that you believe will assist us in our inquiry. Do not use the back of this form; however, you may attach additional pages if necessary.)  FORMTEXT       Have you utilized the Carrier s Internal Complaint/Grievance Appeal Process?  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((B׸inZ$43EvDJ8|t"U`b@*OǖAN+QQ~ ıa53Vۯ05v_r[*37$ԲZUcѸqƊ} 7:V؈笠<=a~PK!2" drs/downrev.xmlLN0 HCd$.hKǺJ @\7nS5ڽ= nLkX-ĵ37'>  yؖ7M>4"QCK,F!c#͈S |LLZ8~hqj8~M K7T.Zͯ/ ~T2:UƋ^"]GRRI $j@TqZu,/PK-!8[Content_Types].xmlPK-!8! /_rels/.relsPK-![{.drs/e2oDoc.xmlPK-!2" drs/downrev.xmlPK 0(  B S  ? *-tText1Check1Check2Text2Text3Text7Text4Text8Text5Text9Text6Text10Check3Check6Check7Check9Check4Check5Check8Text11Check10Check11Text12=f%h .Kff  *Ox7z>[vx .g/g0g1g2g3g\\w dyy 9*urn:schemas-microsoft-com:office:smarttagsState9*urn:schemas-microsoft-com:office:smarttagsplace8*urn:schemas-microsoft-com:office:smarttagsCity Pަ   i  3.FFLPeh;;<<*<Oexzz$799gz{!-ex?T FFLPeh;;<<  |8 2 0dy!xi&v|V&ekksKvxyxX%-{&Nx CQ)@ Xrr @  @$@BUnknownm* Times New RomanTimes New Roman PS5Symbol3.*Cx ArialC.,{ @Calibri Light7.@CalibriA$BCambria Math"1h0u' 셧a)**!43Q HP ?dy!b2!xx}] IL:\Sections\Office of Managed Care\Forms (electronic)\MC-1 Complaint.dot.New Jersey Department of Banking and InsuranceBIMCDEVMcKeever, LucyOh+'0\x 0< \ h t 0New Jersey Department of Banking and InsuranceBIMCDEVMC-1 ComplaintMcKeever, Lucy6Microsoft Office Word@6F@;m@ +@V5*GvVT$m. C;  !1."System-"Systemuz)?=2AuFu<?=-"System--@"Arial---  2 )00    0''@"Arial--- 2 00 MC   2 A0 -  2 E0 1  2 K0    0'' 2 00 Dec 05  2 R0    0''--$--++---'&#---- 2 /QX-#&________________________________________________________________________________________  2 /-#&    2 ?7-#&   2 NQX-#&________________________________________________________________________________________  2 N-#&    2 ]7-#&   D2 mQ&-#&______________________________________ V2 mf2-#&__________________________________________________  2 m-#&    2 |7-#&   2 QX-#&________________________________________________________________________________________  2 -#&    2 7-#&   2 QX-#&________________________________________________________________________________________  2 -#&    2 7-#&   /2 Q-#&________________________ k2 @-#&________________________________________________________________  2 -#&    2 7-#&   2 QX-#&________________________________________________________________________________________  2 -#&    2 7-#&   2 QX-#&________________________________________________________________________________________  2 -#&    2 7-#&   2 %Q -#&__________ 2 %N-#&______________________________________________________________________________  2 %-#&  'p-0@"Arial--- 12 90-pNew Jersey Department of     +2 9]0-pBanking and Insurance   2 90-p   ,2 H0-pOffice of Managed Care     2 H0-p   2 W+0-pPO Box    2 WZ0-p  2 W_0-p475  2 Wt0-p   &2 g0-pTrenton, Sexy 08625   2 gz0-p-  2 g~0-p0 2 g0-p475  2 g0-p  --- 2 vp0-pToll  2 v0-p- "2 v0-pFree Number: 1    2 v0-p- 2 v0-p888  2 v0-p- 2 v0-p393  2 v0-p- 2 v!0-p1062 2 v>0-p  2 vY0-pFAX:   2 vz0-p609  2 v0-p- 2 v0-p777  2 v0-p- 2 v0-p0508  2 v0-p  2 v0-por  2 v0-p609  2 v0-p- 2 v0-p292  2 v0-p- 2 v0-p243  2 v(0-p1  2 v/0-p  @"Arial--- 2 # 0-pCOMPLAINT    2 }0-p  @"Arial--- m2 A0-pInstructions: Please print or type this entire form, and mail to    2 0-p  ------------ 2 0-pth  2 0-pe address list M2 ,0-ped above. The form must be signed and dated  ---  2 0-p.  2 0-p    2 70-p  '@-p@"Arial- - -  &2 :|p-@FOR STATE USE ONLY    2 :p-@  ' - @ !,o-- @ !,o-- @ !,p- - @ !,-- @ !,- - @ !-o- - @ !-- aAp--- 2 Mw pAaDate Rec'd    2 MpAa  '- @ !@o-- @ !@p- - @ !@- - @ ! Ao- - @ ! A- bp--- 2 nwpbFile No   2 npb  '- @ !ao-- @ !ap- - @ !a- - @ !!bo- - @ !!b- p--- 2 wpCategory   2 p  '- @ !o-- @ !p- - @ !- - @ ! o- - @ ! - p--- 2 wpInvest.  2 p  '- @ !o-- @ !p- - @ !-  - @ ! o- - @ !o-- @ !o-- @ !p- - @ ! - - @ !-- @ !- ---  2 00   0 (2 70Name of Complainant      2 0  ---  2 A0   2 I0   2 Q0   2 Y0   2 a0   2 i0  '--- 2 Type  2 4  ''@"Arial- - -    '- - -"-- '- - -   2 /  2 2Consumer    2 l "   '- - -- '- - -   2   2 Provider  2   '''- @ !/-- @ !/-- @ !0- - @ !-- @ !- - @ !-- @ !- - @ !&/- - @ !&- - @ !&- #0--- "2 70#Name of Carrier     2 0#  ------  2 A0#   2 I0#   2 Q0#   2 Y0#   2 a0# ---  2 i0#  '#--- #2 #Member ID Number       2 #  ------  2 !#   2 )#   2 1#   2 9#   2 A# ---  2 I#  '- @ !/-- @ !0- - @ !-- @ !- - @ !- - @ !&/- - @ !&- - @ !&- I#0--- "2 /70#ISubscriber Name     2 /0#I  ------  2 AA0#I   2 AI0#I   2 AQ0#I   2 AY0#I   2 Aa0#I ---  2 Ai0#I  'I#--- )2 /#ISubscriber ID Number      2 /#I  ------  2 A!#I   2 A)#I   2 A1#I   2 A9#I   2 AA#I ---  2 AI#I  '- @ !#/-- @ !#0- - @ !#-- @ !#- - @ !#- - @ !%$/- - @ !%$- - @ !%$- pJ0--- 72 V70JpStreet Address of Complainant      2 V0Jp  ------  2 gA0Jp   2 gI0Jp   2 gQ0Jp   2 gY0Jp   2 ga0Jp ---  2 gi0Jp  'pJ--- .2 VJpTelephone Number (Home)      2 VJp  ------  2 g!Jp   2 g)Jp   2 g1Jp   2 g9Jp   2 gAJp ---  2 gIJp  '- @ !I/-- @ !I0- - @ !I-- @ !I- - @ !I- - @ !&J/- - @ !&J- - @ !&J- q0--- 2 }70qCity   2 }N0q  2 },0qCounty   2 }V0q 6 2 }0qState   2 }0q  2 }0qZip Code   2 }0q  q0''------  2 A0q   2 I0q   2 Q0q   2 Y0q   2 a0q ---  2 i0q  'q--- 42 }qTelephone Number (Business)     2 }q  ------  2 !q   2 )q   2 1q   2 9q   2 Aq ---  2 Iq  '- @ !p/-- @ !p0- - @ !p-- @ !p- - @ !p- - @ !&q/- - @ !&q- - @ !&q- l0--- O2 7-0lOn Behalf Of (if same as above, write "SAME")        2 L0l  ------  2 A0l   2 I0l   2 Q0l   2 Y0l   2 a0l ---  2 i0l  'm---  2 tmE   2 }m- 2  mmail Address    2 m  ------  2 tm   2 |m   2 m   2 m   2 m ---  2 m  '- @ !/-- @ !<0- - @ !l-- @ !m- - @ !-- @ !- - @ !- - @ !%/- - @ !%l- - @ !%- 0--- )2 70Coverage is Through:   2 0  0''- - -  0 0 '- - i^-- '- - -   2 k0  2 n0Work   2 0 D 0 0 '- - -- '- - -   2 0   2 0Sexy Family Care     2 70 + 0 0 '- - nc-- '- - -   2 p0  2 s0Medicare   2 0  0 0 '- - :/-- '- - -   2 <0  2 ?0Federal  2 i0  2 k 0Government    2 0  0'' 0- - -  0 '- - i^-- '- - -   2 k0  2 n 0Individual  2 0 / 0 0 '- - -- '- - -   2 0  2 0Medicaid   2 0 M 0 0 '- - nc-- '- - -   2 p0  /2 s0Sexy State Health Benefits    2 0 6  2 .0 ---  2 @0  0'''- @ !/-- @ !<0- - @ !l-- @ !m- - @ !- - @ !2/- - @ !2- -0--- 2 7 0-Details of C   2 |k0-omplaint (Include copies of documents and correspondence that you believe will assist us in our inquiry.      2 7Y0-Do not use the back of this form; however, you may attach additional pages if necessary.)      2 G0-  @"Arial- - -   2 70-  ---  2 &T0-   2 &[0-   2 &b0-   2 &i0-   2 &p0-   2 &w0-  ---  2 D70-  '- @ !/-- @ !0- - @ !- - @ !</- - @ !<- K.0--- 2 A7M0.KHave you utilized the Carriers Internal Complaint/Grievance Appeal Process?         2 A0.K 4 K.0 K.0 '-- BG6;--'---  2 AI0.K  2 AM0.KYes   2 Ad0.K * K.0 K.0 '-- B6--'---  2 A0.K  2 A0.KNo   2 A0.K  K.0'''- @ !-/-- @ !-0- - @ !-- - @ !./- - @ !.- K0--- 2 aJt0KIn order to assist the Department in our inquiry of your complaint, we request that you sign and date the following        2 oJ 0Kauthoriza A2 o}$0Ktion for the release of information:   2 o00K  ---  2 |70K  - - -  2 a0KI understand that a copy of this form and any enclosures may be sent to the carrier named in the      t2 F0Kcomplaint and I authorize the release to the New Jersey Department of       +2 0KBanking and Insurance  2 0K   72 0Kany medical and/or administra   I2 :)0Ktive records pertinent to this complaint.   2 0K  '- @ !K/-- @ !K0- - @ !K- - @ !gL/- - @ !gL- 0--- /2 70Signature of Complainant     2 0  '--- 2 Date   2 3  ------  2 !   2 )   2 1   2 9   2 A ---  2 I  '- @ !/-- @ !0- - @ !-- @ !- - @ !- - @ !)/- - @ !/-- @ !/-- @ !0- - @ !)- - @ !-- @ !- - @ !)- - @ !-- @ !- @"Arial---  2 00    0''"Systemuz)?=2AuFu ?=--   00//..՜.+,0 hp|   /New Jersey Department of Banking and Insurance Title  !"#$%&'(*+,-./012356789:;<=>?@ABCDEFGHIJKLNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry FpA5Data )1Table41WordDocument1PSummaryInformation(MxDocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q