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.
Insurance Information
Optional
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.