Fillable Dear Consumer, Thank you for contacting the Health (Maryland Attorney General)

Fill Online, Printable, Fillable, Blank Dear Consumer, Thank you for contacting the Health (Maryland Attorney General) Form

Use Fill to complete blank online MARYLAND ATTORNEY GENERAL (MD) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Dear Consumer, Thank you for contacting the Health (Maryland Attorney General)

On average this form takes 19 minutes to complete

The Dear Consumer, Thank you for contacting the Health (Maryland Attorney General) form is 8 pages long and contains:

  • 0 signatures
  • 18 check-boxes
  • 68 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Maryland Attorney General

BROWSE MARYLAND ATTORNEY GENERAL (MD) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Dear Consumer,
Thank you for contacting the Health Education and Advocacy Unit regarding your
complaint against Maryland Health Connection.
Enclosed please find a complaint form and an Authorized Representative Form. To begin
working on your complaint, we will need the following:
❑ Completed complaint form;
❑ Copies of any notices or other correspondence that you have received (please do
not send us original documents);
❑ If you are appealing an Advanced Premium Tax Credit or Cost-Sharing
Reductions determination – Copies of your financial documents (income
information for everyone in the family – paystubs, W-2 forms, wage and tax
statements)(please do not send us original documents); and
❑ Signed and dated Authorized Representative form. (This form is necessary to
allow us to act on your behalf).
Failure to return a signed Authorized Representative form may result in closure of your case.
Please return the above-referenced materials to our office via mail, email or fax:
Office of the Attorney General
Health Education and Advocacy Unit
200 St. Paul Place, 16
th
Floor
Baltimore, MD 21202
Fax: 410-576-6571
heau@oag.state.md.us
Once we have received your materials your case will be assigned to a member of our staff
on a first come, first served basis. You will be contacted by your assigned mediator or
ombudsman once your case is assigned.
BRIAN E. FROSH
Attorney General
WILLIAM D. GRUHN
Chief
Consumer Protection Division
ELIZABETH F. HARRIS
Chief Deputy Attorney General
CAROLYN QUATTROCKI
Deputy Attorney General
STATE OF MARYLAND
OFFICE OF THE ATTORNEY GENERAL
CONSUMER PROTECTION DIVISION
_______________________________________________________________________________________________________________
200 Saint Paul Place ♦ Baltimore, Maryland, 21202-2021
Main Office (410) 576-6300 ♦ Main Office Toll Free (888) 743-0023
Consumer Complaints and Inquiries (410) 528-8662 ♦ Health Advocacy Unit/Billing Complaints (410) 528-1840
Health Advocacy Unit Toll Free (877) 261-8807 ♦ Home Builders Division Toll Free (877) 259-4525 ♦ Telephone for Deaf (410) 576-6372
www.marylandattorneygeneral.gov
Please review the enclosed information explaining the complaint process and our
procedures. If you have any questions, or wish to check on the status of your complaint, please
do not hesitate to contact us at (410) 528-1840 or toll free at (877) 261-8807. Our hotline is open
Monday through Friday from 9:00 a.m. until 4:30 p.m.
Thank you,
Health Education and Advocacy Unit
What is the Health Education and Advocacy Unit (HEAU)?
The Health Education and Advocacy Unit of the Consumer Protection Division of the
Attorney General’s Office is a unit that handles consumer complaints involving a variety of
issues in the healthcare marketplace. Typical complaints include medical billing and
reimbursement problems, medical record access issues, medical equipment sales and warranty
issues, and health insurance disputes. The Unit uses the process of mediation to attempt to
resolve these consumer complaints. If you file a complaint that involves an issue that we cannot
handle, we will attempt to refer your complaint to a more appropriate agency.
What is Mediation?
The process of mediation is one in which a third-party (mediator) works with parties in a
dispute to try to bring about a cooperative settlement. We will gather information about your
dispute and work toward a cooperative resolution of the problem.
Three keys to successful mediation are cooperation, information, and communication.
For mediation to work, the parties to the dispute must be willing to try to resolve the problem.
We find in most cases that businesses and consumers work hard to both avoid problems and to
resolve problems when they arise. We will need information from both you and the business
involved in the complaint.
The primary source of information from you will be the complaint form and the
documents you provide about your complaint. We may call or write to you for additional
information. It is important that you make clear in your complaint what you would like to see as
a result of filing your complaint. We will also contact the businesses involved to seek
information about the dispute and ask what offer the business would propose to resolve the
problem. Most importantly, we will attempt to re-establish lines of communication between you
and the business which will often lead to a resolution of the problem.
What are the Limits of Mediation?
The HEAU can help you file your appeal and can negotiate with Maryland Health
Connection on your behalf prior to your hearing. Unfortunately, if your case proceeds to a
hearing, the HEAU CANNOT REPRESENT YOU IN THE HEARING OR IN COURT OR
OTHERWISE ACT AS AN ATTORNEY. If our mediation efforts are not successful, we will
close your complaint file.
Is My Complaint Public Information?
We are required to make available some information from your complaint file upon
request. However, to the extent that disclosure could reveal medical, psychological, or financial
information, that information will not be released.
Health Education and Advocacy Unit Page 1 www.MarylandCares.org 877-261-8807
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.
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.
Medicaid Denials: The HEAU is unable to help consumers with Medicaid Eligibility denials.
INFORMATION ABOUT YOU
First Name:_________________________ Middle Initial:_____ Last Name:________________________
Date
of Birth:________________________ Email Address:____________________________________
Add
ress Line 1:_________________________________________________________________________
Add
ress Line 2:_________________________________________________________________________
City
:__________________________ State:________ Zip:_____________ County:___________________
Daytime Telephone Number: ___________________ Alternate Number: __________________________
Maryland Health Connection ID:___________________________________________________________
OTHER FAMILY MEMBERS LISTED ON THE APPLICATION FOR COVERAGE
Name:______________________________ Date of Birth:___________ Relationship:________________
Nam
e:______________________________ Date of Birth:___________ Relationship:________________
Nam
e:______________________________ Date of Birth:___________ Relationship:________________
Attach additional sheets if needed.
WHY DO YOU WANT A HEARING?
_______ I was not allowed to apply for coverage through Maryland Health Connection.
_______ I was told I did not qualify for an Advanced Premium Tax Credit.
_______ I was told I did not qualify for Cost-Sharing Reductions.
_______ I do not agree with the amount of my Advanced Premium Tax Credit.
_______ Other:
Health Education and Advocacy Unit Page 2 www.MarylandCares.org 877-261-8807
DID YOU RECEIVE A NOTICE FROM MARYLAND HEALTH CONNECTION?
Yes _____ No_____ 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? Yes _____ No_____
Navigator _____ Call Center Representative _____ Unknown _____
Name of Person: ______________________________________________________________________
What have they told you about your complaint?
Is there additional information you would like to add?
How did you hear about us?
Health Education and Advocacy Unit Page 3 www.MarylandCares.org 877-261-8807
HAVE YOU FILED AN APPEAL ALREADY?
Yes _____ No_____ Date:__________________________________
How did
you file your appeal? Phone _____ Email_____
Mailed to: Maryla
nd Health Connection _____ Office of Administrative Hearings _____
DID YOU ENROLL IN A HEALTH INSURANCE PLAN?
Plan Name _______________________________ Type of Plan ____________________________
Members
hip Number/ID Number ____________________________________________________
IMPORTANT INFORMATION
1. The HEAU cannot help you with your appeal without a signed Authorized Representative Form.
Please fill out Sections I, IV and V, and below Section V on the attached Authorized Representative
Form and return the form to us.
2. If you are appealing an Advanced Premium Tax Credit or Cost-Sharing Reductions determination we
will need to have your financial information to help you. Please send in any financial information you
have to support your claim. Please do not send us any original documents.
3. If you are appealing an Advanced Premium Tax Credit or Cost-Sharing Reductions determination we
will need to obtain the IRS information that Maryland Health Connection used to make their decision. In
order to receive that information we need your permission. Please sign the attached Federal Tax
Information (FTI) Form and return the form to us. Note: This form is not yet finalized and approved by
the IRS. We will send you this form once it is approved.
4. The HEAU can help you file your appeal and can negotiate with Maryland Health Connection on your
behalf prior to your hearing. Unfortunately, if your case proceeds to a hearing, the HEAU cannot
represent you at that hearing.
5. A copy of the complaint form and any documents you provide us may be sent to Maryland Health
Connection and their authorized agents. If your complaint should be referred to another State or
Federal agency (ex. Maryland Insurance Administration, Department of Health and Mental Hygiene) we
will forward your complaint to that agency. By filing a complaint with our office you are authorizing us
to forward your complaint to another State or Federal agency, if appropriate.
6. Complaints submitted to our office become matters of public record; however, all or part of the
complaint may remain confidential as required or permitted by Maryland's public records law. For
example, in healthcare-related complaints filed with our office, medical or psychological information
about an individual will not be disclosed to the public. Financial information will not be disclosed.
SIGNATURE
Complainant Signature:____________________________________ Today’s Date:_________________
Health Education and Advocacy Unit Page 4 www.MarylandCares.org 877-261-8807
Submit this completed Complaint Form, Authorized Representative Form, MHC Notice, Federal Tax
Information Form (this form has not been finalized), financial information and any other supporting
documents via mail, fax or email to:
Office of the Attorney General, Health Education and Advocacy Unit
200 St. Paul Place, 16
th
Floor
Baltimore, MD 21202
Fax: 410-576-6571
Email: heau@oag.state.md.us
Ple
ase DO NOT send us original supporting documents.
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 your documents as soon as possible.
MARYLAND HEALTH BENEFIT EXCHANGE
RELEASE OF INFORMATION AUTHORIZATION FORM
COMPLETE ALL SECTIONS, DATE, AND SIGN
I. I,
Print Name of Individual
, hereby voluntarily authorize the disclosure of my Personally Identifiable
Information related to my application for health insurance, Advanced Payment
Tax Credits, Cost Reduction Sharing and/or other benefits provided to the
Maryland Health Benefit Exchange.
II. The information is to be disclosed by:
And is to be provided to:
NAME OF FACILITY
NAME OF PERSON/ORGANIZATION/FACILITY
ADDRESS ADDRESS
CITY/STATE CITY/STATE
III. The purpose or need for this disclosure is:
Personal Use Attorney Disability Other (Specify)
Insurance
School
IV. The information to be disclosed from my enrollment application(s): (check appropriate box(es))
Only information related to (specify)
Only the period of events from to
Other (specify)
Entire Record
Written correspondence generated by MHBE related to my application.
If you would like any following sensitive information not to be disclosed, please list:
_______________________________________________________________________________________________________________________
V. I understand that I may revoke this authorization in writing submitted at any time to the MHBE Custodian of Records, except to the extent that
action has been taken in reliance on this authorization. If this authorization was obtained as a condition of obtaining insurance coverage or a policy of
insurance, other law may provide the insurer with the right to contest a claim under the policy. If this authorization has not been revoked, it will terminate
one year from the date of my signature unless a different expiration date or expiration event is stated.
(Specify new date)
I understand that MHBE will not condition eligibility for cost saving reductions, APTC or other benefits on my providing this authorization. This authorization
extends only to the records generated by MHBE and does not include records created by third parties. It is my responsibility to request records directly
from the generating party.
I understand that information disclosed by this authorization may be subject to re-disclosure by the recipient and may no longer be protected under
Maryland law and the Privacy Act of 1974 [5 USC 552a].
SIGNATURE OF INDIVIDUAL OR AUTHORIZED REPRESENTATIVE (State relationship to individual)
DATE
SIGNATURE OF WITNESS (If signature of individual is a thumbprint or mark)
DATE
This information is to be released for the purpose stated above and may not be used or re-disclosed by the recipient for any other purpose. Any person who knowingly and willfully
requests or obtains any record concerning an individual from a State agency under false pretenses shall be guilty of a misdemeanor.
The below information must be
completed in its entirety in order for MHBE to release the requested information.
ADDRESS DATE OF BIRTH (mm/dd/yyyy)
STREET CITY, STATE, AND ZIP CODE
NAME (Last, First, MI)
Last 5 digits of Record Holder’s OR MHBE Personal Identification Number
Social Security Number (PIN)
MHBE – 02.01.01.01 Release of Information Authorization Form 5-12-2020
Office of the Attorney General
Maryland Health Connection
Health Education and Advocacy Unit
PO Box 857
200 St. Paul Place, 16th Floor
Lanham, MD 20703
Baltimore, MD 21202
✔
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Dear Consumer, Thank you for contacting the Health (Maryland Attorney General)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document