ODI - Complaints Form

If you are a pharmacy wishing to file a complaint regarding a pharmacy benefits manager, please use our PBM Complaints Form

Please provide your basic contact information in case we need to follow up on your complaint.

Middle Name

Address Line Two

Phone Number

I am the insured person associated with this complaint.
I am not the insured person associated with this complaint.
I am a healthcare provider submitting this complaint on behalf of a patient.

Group Number

Policy Number

Claim Number

Level of Coverage

Sublevel of Coverage

Optional

Check here if an agent/broker was involved with this complaint.

Agent Address Line 1

Agent Address Line 2

Agent City

Agent State

Agent Zip Code

Agent Email Address

Agent Phone Number

Incident Date Incident Date (!)

Please provide as many details as possible regarding your complaint.

Please describe your expected resolution for your complaint.

Reason for Complaint - Select up to three (3) items

If you have any supporting documentation, please attach it below. Supported file types are pdf, doc, docx, xls, xlsx, png, jpg, tiff, rtf, bmp, gif, txt.

Public Records

This complaint form, all documents you send us, and any document received by our office as a result of handling your complaint may be a public record, subject to Ohio's Public Records Act. This law requires all public records to be available for inspection by anyone, upon request.

Supporting Document One

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Supporting Document Two

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Supporting Document Three

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To the best of my knowledge the above statement is correct. I understand that a copy of this form and any attachments may be sent to the insurance company or agent involved. I authorize the insurance company to release all of the medical records relating to this complaint to the Ohio Department of Insurance and I authorize the Ohio Department of Insurance to release medical records relating to this complaint to the insurance company or agent as necessary in order to resolve this complaint. I represent that I have the proper authority to execute this release.

I agree

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Consumer Complaints Form

Contact Information

Insurance Information

Complaint Description

Complaint Reasons

Supporting Documentation

Public Records

Submit Complaint