GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS
GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE CONSUMER ASSISTANCE PROGRAM COMPLAINT FORM COMPLAINANT: Insured/Provider: ______________________________________________________ Mailing Address: ______________________________________________________ Telephone No.: (_____) ______________ (Home) (_____)_______________(Work) (_____) _______________(Other) E-Mail:_________________________ Gender: ❑Male ❑ Female Date of Birth (mm/dd/yyyy): ______________________ Language: ❑ English ❑ Spanish ❑ Other ____________ Status: ❑ Insured ❑Uninsured Insurer: ________________________________ Policy Number: ______________ STATUS OF COMPLAINANT: ❑ INSURED ❑PROVIDER ❑EMPLOYER ❑BROKER ❑AGENT ❑OTHER COMPLAINT AGAINST: ❑AGENT ❑BROKER ❑PROVIDER ❑EMPLOYER/ADMINISTRATOR X INSURANCE COMPANY ❑OTHER Indicate Individual’s/Company’s Name: __________________________________________ Address: ___________________________________________________________________ Telephone No.: _____________________ Facsimile No.: __________________ E-Mail: _____________ …
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GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE CONSUMER ASSISTANCE PROGRAM COMPLAINT FORM COMPLAINANT: Insured/Provider: ______________________________________________________ Mailing Address: ______________________________________________________ Telephone No.: (_____) ______________ (Home) (_____)_______________(Work) (_____) _______________(Other) E-Mail:_________________________ Gender: ❑Male ❑ Female Date of Birth (mm/dd/yyyy): ______________________ Language: ❑ English ❑ Spanish ❑ Other ____________ Status: ❑ Insured ❑Uninsured Insurer: ________________________________ Policy Number: ______________ STATUS OF COMPLAINANT: ❑ INSURED ❑PROVIDER ❑EMPLOYER ❑BROKER ❑AGENT ❑OTHER COMPLAINT AGAINST: ❑AGENT ❑BROKER ❑PROVIDER ❑EMPLOYER/ADMINISTRATOR X INSURANCE COMPANY ❑OTHER Indicate Individual’s/Company’s Name: __________________________________________ Address: ___________________________________________________________________ Telephone No.: _____________________ Facsimile No.: __________________ E-Mail: ________________________________________________ Complaint No.: ________________ Date Opened: _________________ Date Resolved/Closed: _______________ CONSUMER ASSISTANCE PROGRAM COMPLAINT FORM Kongens Gade No. 5049, Charlotte Amalie, St. Thomas VI 00802 • Tel: (340) 774-7166 • Fax: (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Tel: (340) 773-6459 • Fax: (340) 719-3801 TYPE OF COVERAGE: ❑AUTOMOBILE BODILY INJURY ❑INDIVIDUAL HEALTH ❑GROUP HEALTH ❑OTHER _____________ REASON FOR COMPLAINT: ❑ PREMIUM RATES ❑ REFUSAL TO INSURE ❑ ACCESS/COVERAGE ❑ CANCELLATION/RENEWAL/RECISSION ❑ AGENT HANDLING ❑ REIMBURSEMENT CHALLENGES ❑CARE IS EXPIREMENTAL/INVESTIGATIONAL ❑ MISLEADING ADVERTISING ❑ DENIAL OF CLAIM/NON PAYMENT ❑ CLAIM HANDLING DELAYS ❑UNSATISFACTORY SETTLEMENT ❑ PREEXISTING CONDITION ❑ NOT ELIGIBLE FOR HEALTH PLAN/BENEFITS ❑CARE IS NOT MEDICALLY NECESSARY ❑QUALITY OF SERVICE ❑ MISREPRESENTATION ❑ OTHER: _______________ SUMMARY / REASON FOR COMPLAINT: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ CONSUMER ASSISTANCE PROGRAM COMPLAINT FORM Kongens Gade No. 5049, Charlotte Amalie, St. Thomas VI 00802 • Tel: (340) 774-7166 • Fax: (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Tel: (340) 773-6459 • Fax: (340) 719-3801 EXAMINER’S FINDINGS: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _________________________ _______________________ Signature Date Hearing Requested By: __________________ Hearing Date: _________________ Notice of Penalty: ___________________ Penalty Imposed: _________________ Court Action: _______________________ Date: __________________________ CONSUMER ASSISTANCE PROGRAM COMPLAINT FORM Kongens Gade No. 5049, Charlotte Amalie, St. Thomas VI 00802 • Tel: (340) 774-7166 • Fax: (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Tel: (340) 773-6459 • Fax: (340) 719-3801 PROVIDE/ATTACH ANY DOCUMENTATION THAT IS IMPORTANT OR PERTAINS TO THIS COMPLAINT SUCH AS THE DENIAL FROM YOUR INSURER OR LETTERS FROM YOUR TREATING PHYSICIAN. IMPORTANT: Consent Form for Consumer Assistance Program to assist me with my appeal/complaint. The undersigned individual has requested assistance from the Division of Banking and Insurance’s, Consumer Assistance Program as provided pursuant to Sec. 2793 (Health Insurance Consumer Information) Part C of the Public Health Service Act (300gg-93) and consents to the assistance by the Consumer Assistance Program(CAP)and its agents or employees. The undersigned acknowledges that the information and assistance provided by CAP does not constitute legal representation and that CAP may not serve as the undersigned’s authorized representative in any hearing or in any other capacity. The undersigned acknowledges that there shall be no liability on the part of, and no cause of action of any nature shall arise against, CAP or its agents or employees, the Division of Banking and Insurance or its agents or employees, or the Commissioner or the Commissioner's representatives for any action taken by them in good faith in the performance of their powers and duties. _____________________________ (Print) ___________________________ (Sign) __________________________ (Date) CONSUMER ASSISTANCE PROGRAM COMPLAINT FORM Kongens Gade No. 5049, Charlotte Amalie, St. Thomas VI 00802 • Tel: (340) 774-7166 • Fax: (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Tel: (340) 773-6459 • Fax: (340) 719-3801 IMPORTANT: Release of your medical information. The undersigned individual has requested assistance from our Consumer Assistance Program, under the office of the Lieutenant Governor, Division of Banking and Insurance. In order to facilitate this assistance, the undersigned authorizes Consumer Assistance Program to obtain from the health plan or health insurance issuer involved, and their sub- contractors, all information relating to the matter in question, including, but not limited to, the individual’s files and medical record information. Payment of fees, if any, for obtaining these records is the responsibility of the undersigned. All patient medical records in the possession of CAP shall be confidential. This authorization will automatically expire upon final resolution of the matter giving rise to the undersigned’s request for CAP assistance. The undersigned may revoke this authorization at any time. Revocation of this authorization will be effective upon receipt, but will not affect actions already taken on the basis of this authorization. ___________________________ (Print) __________________________ (Sign) _____________________ (Date)