PROVIDER COMPLAINT FORM

If you are a doctor, hospital or other health care provider who has been denied payment by a health insurer or health plan for services you rendered to a patient whose claim was denied, or whose coverage was dropped, cancelled or rescinded altogether, please answer the questions on the following short form:

1. Beginning in 2004 until now, what health plan(s)/insurer(s) have denied payment to you in this fashion?

   Aetna Assurant (formerly FORTIS) AXA Blue Cross Blue Shield Cigna CPIC Life Fairmont Globe Health Net Kaiser Metropolitan New York Life Pacificare Prudential Security Life Standard Time

   Use Ctrl + Left Mouse Button to select all that apply.

   
   Name of company, if not in above list:
   
     
2. In what city, region or state do you work?
   < Select Region > City of Los Angeles County of Los Angeles Southern California (Non-L.A./L.A. County) Other part of California Other State     Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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
    
3. What is the approximate total dollar amount of the fee(s) for which you have been denied payment in this fashion by all health plans/insurers combined, since January 1, 2004?
   < Select Value > Less than $1,000 $1,000 - $5,000 $5,000 - $10,000 $10,000 - $50,000 More than $50,000
    
4. In the box below, you may provide additional information about your experience with being denied payments by health plans/insurers who have denied the claims of their insureds or members, or canceled their coverage altogether: (maximum 250 words)
   
    
5. Consistent with your confidentiality obligations to your patients, we would like to discuss this matter more fully with you. Please give us your contact information:
   

   First Name	Last Name
   Address
   Phone Number where we can reach you:
   Best time to call you: Day Evening Weekend All
   EMail

IMPORTANT NOTICE:
The Office of the Los Angeles City Attorney represents the People of the State of California in criminal and civil law enforcement cases. The Office of the Los Angeles City Attorney cannot represent you individually, nor can we refer you to a private attorney for representation. This website is intended solely to gather information for a law enforcement investigation regarding potentially unlawful, fraudulent or unfair business practices of health care plans and health care insurers. If you choose to provide information on this website, it may be used for law enforcement purposes, including all legal proceedings that may result from this investigation. During the course of the investigation, we will make every reasonable effort to maintain the privacy and confidentiality of the information you provide. However, in the event that a civil or criminal case is filed against the health care plan or health insurer that is the subject of your complaint, it may be necessary to disclose your information in the resulting court proceedings.

If you are currently represented by a private attorney in a dispute against a health care plan or health insurer, we urge you to consult with your attorney before providing us with the information requested above.

 I have read and I understand this notice, and I am voluntarily providing the
       information submitted herewith to the Office of the Los Angeles City Attorney.