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Medicaid Managed Care Complaint Form Managed Care Ombudsman Program Office of the State Long-Term Care Ombudsman Date: ____________________________________ Individual Submitting Complaint: ______________________________________________________________ Relationship to Medicaid Managed Care Member: ________________________________________________ Address: __________________________________________________________________________________________ __________________________________________________________________________________________ Phone: ____________________________________ Alternate Phone: __________________________ Email:_____________________________________________________________________________________ Medicaid Managed Care Member: _____________________________________________________________ Medicaid ID: _______________________________ Managed Care Organization: Medicaid Program: ________________________ Amerigroup Iowa Total Care Fee for Service Please describe your complaint(s) below: Complaint: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ (continued on the next page)
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Page 1: Medicaid Managed Care Complaint Form · Managed Care Organization (MCO) Department of Human Services Medicaid Provider: _____ Case Manager: _____ Other: _____ Would you like to be

Medicaid Managed Care Complaint Form Managed Care Ombudsman Program

Office of the State Long-Term Care Ombudsman

Date: ____________________________________

Individual Submitting Complaint: ______________________________________________________________

Relationship to Medicaid Managed Care Member: ________________________________________________

Address:

__________________________________________________________________________________________

__________________________________________________________________________________________

Phone: ____________________________________ Alternate Phone: __________________________

Email: _____________________________________________________________________________________

Medicaid Managed Care Member: _____________________________________________________________

Medicaid ID: _______________________________

Managed Care Organization: Medicaid Program: ________________________ Amerigroup Iowa Total Care Fee for Service

Please describe your complaint(s) below:

Complaint: __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________ (continued on the next page)

Page 2: Medicaid Managed Care Complaint Form · Managed Care Organization (MCO) Department of Human Services Medicaid Provider: _____ Case Manager: _____ Other: _____ Would you like to be

Complaint continued:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Other Entities Contacted: Managed Care Organization (MCO)

Department of Human Services

Medicaid Provider: _________________________________________________________________

Case Manager: ____________________________________________________________________

Other: ___________________________________________________________________________ Would you like to be contacted by the Managed Care Ombudsman Program to discuss the complaint(s) indicated on this form?

Yes No

The Managed Care Ombudsman Program will keep a confidential record of the complaint(s). By submitting the Medicaid Managed Care Complaint Form you are consenting for the Managed Care Ombudsman Program to contact the necessary parties to resolve the complaint(s) reported. The Managed Care Ombudsman Program reserves the right to contact the individual submitting the complaint and/or the Medicaid Managed Care Member as necessary. Signature of Individual Submitting Complaint: ____________________________________________________ Signature of Medicaid Managed Care Member: ___________________________________________________ Please submit this form directly to:

Mail: Office of the State Long-Term Care Ombudsman Attn: Managed Care Ombudsman Jessie M. Parker Building 510 E 12th Street, Suite 2 Des Moines, IA 50313-9025

Fax: 515-725-3313

Email: [email protected] **Please note that this form is only intended for the Office of the State Long-Term Care Ombudsman and the Managed Care Ombudsman Program. If a complaint needs to be filed with the Managed Care Organization or the Department of Human Services, a separate form will need to be completed.

mailto:[email protected]

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