Ohio Department of Insurance

Consumer Complaints Form

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

Contact Information

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

Name


Phone and Email

Insurance Information

Insured's Name





Insurance Details

Optional


Agent Information

Agent Address

Complaint Description

Please provide as many details as possible regarding your complaint.

Please describe your expected resolution for your complaint.

Complaint Reasons

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

Supporting Documentation

If you have any supporting documentation, please attach it below.

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.

Submit Complaint

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.

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