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Maine.gov > PFR Home > Insurance Regulation > Consumer Complaint Form

STATE OF MAINE
HEALTH CARE DIVISION CONSUMER COMPLAINT FORM

Please note: Although it is most unlikely that you will experience any problems using this form, certain non-standard browsers will not respond properly. If you experience any difficulties or if you are not using a forms-capable browser you may send an email to: David.G.Stetson@maine.gov or Bradford.L.Brown@maine.gov.


Important information about filing a complaint

In response to your request for our assistance, please complete this Consumer Complaint Form and return it to this office. The form authorizes the Bureau to investigate the matter on your behalf; and provides us the basic information we need to investigate your complaint. The form may be submitted either electronically or by mail. Once received by the Bureau your file will be confidential as provided by Maine law.

PHOTOCOPIES of any correspondence, insurance policies, or other documentation related to your insurance problem, such as notices from the insurance company, explanations of benefits, appeal decisions, and a copy of your policy, may be necessary in order for the Division to act upon your complaint.

Your complaint will be assigned to a Claims Investigator who will contact you by mail for more information at the beginning of the investigation and will advise you of our conclusions once the investigation has been completed. This usually takes a minimum of thirty days.

We will make every effort to assist you and to see that insurance companies comply with Maine insurance laws.

 


(PLEASE CHECK ALL THAT APPLY)








Your Information











Insurance Information












Agent Information (if applicable)







Consumer Authorization

I hereby authorize that any hospital, physician, osteopath, chiropractor or other health care provider, or any person, or company regulated by the Maine Bureau of Insurance, to provide the Bureau with any medical information or records needed by the Bureau to investigate my complaint. I specifically authorize release of information about mental health and substance abuse treatment as needed to investigate this complaint. This authorization remains in effect 12 months from the date the authorization is signed or until I revoke it in writing.




 


 

Last Updated: August 22, 2012