PHYSICIAN/PROVIDER COMPLAINT FORM
(Forma para una Queja)

Click here for Spanish version.

Click here for PDF (printable) version.

Assistance for Providers: TDI´s most important goal is to ensure the availability and affordability of insurance products to Texans. Physicians and other health care providers are an important part of that effort. TDI is committed to make every effort to address problems and concerns that providers may have with insurers, HMOs, and other entities that we regulate.

Help us provide you with the best service:

  • Submit one form for each patient´s/insured´s claim.
  • Refer to the patient´s insurance card information when filling out the complaint form. Or even better, fax or mail us a copy of the insurance card.
  • You may file this form two ways: print this form, fill in the information, and mail or fax it to TDI, or fill out the form on-line. In either case, for complaints involving claim payments or claim delays, be sure to fax or mail the additional documents requested. If you file your complaint on-line, print a copy of your complaint form before submitting it and attach the copy to your supporting documents. It will help speed up the process.
Fax: 512-475-1771
Mail: Texas Department of Insurance
PO Box 149091
Austin TX 78714-9091

Confidential Information: You may disclose confidential medical information when filing your complaint. Be sure you follow the confidentiality guidelines for your profession.

Privacy Policy: Filling out this web-based form may require you to disclose personal information about an individual, such as an individual's name, social security number, group number, and complaint information. Please refer to our Web Site Privacy Policy for further information on how this information will be used.

Open Records: Please be aware that the information you submit to TDI, whether it is through this web-based form or through the mail, may be considered a public record and therefore subject to the Texas Public Information Act. Please refer to our Open Records Policy for further information.

This form is encrypted to meet privacy requirements.

 

 

*Required Field (* Información Requerida)

* Date (mm/dd/yyyy) (Fecha) (mm/dd/yyyy)

* Physician/Provider/Clinic´s Name (Nombre del Asegurado o quien reclama)

* You are a: (Usted es) Physician (Doctor) Provider (Field of licensure) (Proveedor de servicio médico)

Attention: (Atención:)

Your E-mail Address

* Address (Domicilio) (Casa)

* City (Ciudad)

* State (Estado)

* Zip Code (Código Postal)

Phone (Work) (Teléfono) (Trabajo)

Fax

POLICY INFORMATION (Información Sobre la Póliza)

* Patient´s Name: Member/Insured (Nombre del Paciente: Miembro/Asegurado)

Patient´s Social Security Number (Número de Seguro Social del paciente)

Primary Insured´s Name: (Nombre del Asegurado Principal)

Primary Insured´s Social Security Number (Número de Seguro Social del paciente)

Address (Dirección)

City (Ciudad)

State (Estado)

Zip Code (Código Postal)

Complaint is Against: Insured´s/Patient´s insurance company or HMO Utilization Review Agent Third Party Administrator Indemnity Plan Self-Funded Plan
Other (please specify)

La queja es contra: Aseguranza del Paciente/Asegurado Agente de Revisión de Utilización Seguro de Responsabilidad ante Terceros Plan de Indemnización Planes Autónomos Otro (por favor específique)

Type of Coverage: HMO PPO Medicare Supplement
Other (please specify)

Tipo de Cobertura: Organización de Mantenimiento de Salud
PPO Suplemento de Medicare
Otro (por favor específique)

Date(s) of Treatment (Fecha del tratamiento)

Please refer to the patient´s/insured´s health insurance ID Card for answers to the following questions or provide a copy of the member´s health insurance card: (Por favor mire la tarjéta de seguros del asegurado/paciente para las respuestas de las siguientes preguntas o adjunte una copia de la tarjeta:)

* Name of Patient´s/Insured´s HMO or Insurance Company (Nombre de la Compañía de Seguros/ó HMO)

* Member Number (Número Individual de la Póliza)

* Group Policy No. (Número de Grupo - de la póliza)

Patient/Insured PCP´s Medical Group (Número del Certificado)

Effective Date of Coverage (Tipo de Cobertura)

Policy or Claim No. (Número de Póliza o de la Reclamación)

My Complaint is: Mi Queja Es:
Slow Payment of Claims (Reclamo de Pronto Pago) Incorrect Payment of Claims (Reclamo de Pago Incorrecto) Referral Issues (Recomendación)
Prescriptions/Drug Formularies Recetas/Lista de Medicinas Provider Relations/Customer Service Relaciones del Proveedor/Servicio al Cliente Medical Necessity Necesidad de Tratamiento Medico
Denial of Claims (Rechazo de Reclamación) Preauthorization/Precertification (Preautorizatión/Precertificatión)
Other (please specify) Otro (por favor espicifique)

(Please describe your complaint.) (por favor explicar su queja.)

What do you consider to be a fair resolution to your problem?
(¿Qué considera usted una justa solución a su problema?)

_________________________________________________
PROVIDER´s REPRESENTATIVE´s SIGNATURE
(FIRMA DEL ASEGURADO O DE QUIEN PONE LA QUEJA)
Signature not required for those who submit the form online.
(La firma no es necesaria cuando la queja se transmite electronica)

(Please print a copy of the completed complaint form for your records and for use when mailing in supporting documents.)
(Por favor imprima una copia de la forma llena para sus archivos)