OFFICE OF THE ATTORNEY GENERAL, CONSUMER PROTECTION DIVISION
HEALTH EDUCATION AND ADVOCACY UNIT
COMPLAINT FORM


Request for Assistance with an Appeal of Maryland Health Connection Denial

This form is to be used by any person who requests help in filing an appeal of a Maryland Health Connection decision denying Qualified Health Plan coverage or denying Advanced Premium Tax Credits or Cost-Sharing Reductions. This form may also be used to request help for unresolved problems with enrolling in coverage or renewing coverage in a Qualified Health Plan through Maryland Health Connection.
Medicaid Denials: The HEAU is unable to help consumers with Medicaid Eligibility denials.

IMPORTANT: You only have 90 days from the date of the Maryland Health Connection notice
to ask for a hearing. It is very important to provide us with your documents as soon as possible.


Fields with a RED * are required.                    
INFORMATION ABOUT YOU
*First Name:
*Last Name:
*Date of Birth:
*Address Line 1:
 Address Line 2: 
*City: *State: *Zip: *County:
*Daytime Phone Number:             Alternate Number:
*Email Address:       MHC ID#:
OTHER FAMILY MEMBERS LISTED ON THE APPLICATION FOR COVERAGE  
Name (1)Name (2)Name (3)Name (4)Name (5)Name (6)  If there are more than six persons please send us their names, dates of birth and relationship to you when you send in your other documents.
Date of Birth:Date of Birth:Date of Birth:Date of Birth:Date of Birth:Date of Birth:
Relationship:Relationship:Relationship:Relationship:Relationship:Relationship:
WHY DO YOU WANT A HEARING ?

DID YOU RECEIVE A NOTICE FROM MARYLAND HEALTH CONNECTION ?
           Date of Notice: 
What were the reason(s) listed for your denial?
Why do you disagree with the reason(s) listed?

ADDITIONAL INFORMATION
Have you spoken with anyone at Maryland Health Connection or to a Navigator?         

Navigator   Call Center Representative   Unknown

Name of Person(s): You may list as many persons as needed separated by commas.
What have they told you about your complaint?

Is there additional information you would like to add?

How did you hear about us?

HAVE YOU FILED AN APPEAL ALREADY ?
           Date:

How did you file your appeal?
   
 
Mailed to:
   

DID YOU ENROLL IN A HEALTH INSURANCE PLAN ?
Plan Name: Type of Plan:
Membership Number/ID Number: