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SHIBA COMPLAINT FORM

* Denotes required fields

Contact Information
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Insurance Coverage:
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Medicare Coverage:
Billing Issues

Please include dates of service, claim #s, dollar amounts, and provider's names.

Complaint Against Agent/Broker
Information on Enrollment Issues
Complaint
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These should include such things as agencies you have reported this to, calls you have made to try and resolve this, additional parties involved, etc. Also, please attach any documentation such as billing notices, Medicare Summary notices, or letters that support your complaint (for example: a dis-enrollment letter from an insurance company) that you feel would help us to resolve this complaint.

Final Steps

I authorize a SHIBA or SMP representative to request and receive any information on my behalf in connection with my complaint. I understand that personal medical information related to my complaint may be disclosed to a SHIBA or SMP representative.

Do you agree to the above terms and authorization?

Do you have any files to attach?