CLAIMS OID 11/04
COMPLAINT
Please give as detailed information as possible including dates, explanation, and what solution you feel is correct. Attach copies of any
other correspondence related to the complaint.
_____________________________________________________________________________
INQUIRY
Please give as detailed information as possible including dates, explanation, and what solution you feel is correct. Attach copies of any
other correspondence related to the complaint.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
INQUIRY/COMPLAINT
Please give as detailed information as possible including dates, explanation, and what solution you feel is correct, Attach copies of any
Other correspondence related to the complaint.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
(Continue on the back)
With this knowledge, I give my consent to the release of all information in my medical records including any information concerning my
identity and release the OKLAHOMA INSURANCE DEPARTMENT and its duly authorized agents and employees from any liability in
connection with the release of the information contained herein.
Signature:______________________________________________________Date:__________________________________________
FOR INSURANCE DEPARTMENT USE ONLY
Complaint number ____________________ Claim Analyst __________
Complainant type ________________ Complainant letter __________
Entity number 1. __________ 2. __________ 3. __________
Entity type 1. __________ 2. __________ 3. __________
Entity function 1. __________ 2. __________ 3. __________
Entity letter 1. __________ 2. __________ 3. __________
Date Entered _______________________ Med. Supl. (A-J) __________
Coverage _________ 1. __________ 2. __________ 3. __________
Reason for complaint 1. __________ 2. __________ 3. __________
Dispositions 1. __________ 2. __________ 3. __________
Inquirer ___________________________________________________
(If not same as above)
Date resolved ____________________ Amount $__________________
OKLAHOMA INSURANCE DEPARTMENT
Five Corporate Plaza
3625 NW 56th, Suite 100
OKLAHOMA CITY, OK 73112
DATE: ___________________________
FROM: __________________________________________________ Telephone # (_____)_____-________
Address: ___________________________________ City/State: _______________________ Zip: ___________
If Insured or Health Maintenance Organization (“HMO”) member is different than person requesting assistance, complete the
following:
Insured or HMO Member’s name: __________________________________________ Telephone #: (______)______-___________
Address: ___________________________________________ City/State: _____________________________ Zip: _______________
Name of INSURANCE CO. about which you are requesting assistance:________________________________
Address: ___________________________________________ City/State: _____________________________ Zip: _______________
Policy Number:__________________ Effective Date: ________________ Type of Insurance:_______________________________
(Auto, Home, Commercial, Accident & Health)
Agent’s Name:___________________________________________Telephone No.: _(_______)________________________________
Address:____________________________________________City/State_______________________________Zip________________
Adjuster’s Name:_________________________________________Telephone No.: _(_______)_______________________________
Address:____________________________________________City/State_______________________________Zip______________
Name of HMO about which you are requesting assistance:_____________________________________________________
Address: __________________________________________ City/State: _____________________________ Zip: _______________
Member ID Number or SSN:______________________________ Date/s of Service: ______________________________________
Provider’s (Doctor) Name:_________________________________Telephone No.: _(_______)_______________________________
Address:____________________________________________City/State_______________________________Zip________________
Provider’s (Hospital) Name:________________________________Telephone No.: _(_______)_______________________________
TO:
Mr.
Mrs.
Ms.
REQUEST FOR ASSISTANCE
Consumer Assistance
Phone: 1-800-522-0071
Local: 405-521-2991
Fax: 405-521-6652
CLAIMS OID 11/03
INQUIRY/COMPLAINT (continued)
