Iowa Medical Society
Health Plan Complaint Form


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Date:
Practice/Physician Name:
Contact Person at Office:
Street Address:
City:
State:
Zip:
Telephone:
Fax:
E-mail Address:
Name of Insurance Carrier (commercial):

Wellmark Blue Cross Blue Shield - Please specify product, (i.e., Alliance Select, Wellmark Health Plan, etc.)
John Deere Health Plan
Coventry Health Care of Iowa/Nebraska
Midlands Choice
Secure Care of Iowa
United Healthcare of Midlands
Other (please specify):
Payor Type:
Indemnity
HMO
PPO
IPA/Medical Group
ODS
Medicare
Medicaid
hawk-i
Workers Compensation
Other (please specify):
This complaint is a:
First time problem
Recurring problem
This complaint:
Has been resolved and I am reporting to IMS.
Has been brought to the plan's attention but has not been resolved.
Has not been brought to the plan's attention and has not been resolved.
Type of Problem (check all that apply to this complaint):
Appeals process problem  
Audit
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