Claims BureauNew York State Attorney General 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Consumer Information' section. Enter your name, home and work telephone numbers, street address, city/town, county, state, and zip code clearly.
3. Next, move to the 'Complaint Information' section. Provide the name and address of the person or company you are complaining about, along with their telephone number and the date(s) of service.
4. Indicate how you paid for the service by checking the appropriate boxes (Cash, Check, Credit Card, Other).
5. Fill in details about your health plan including its name and your identification number. If applicable, provide information regarding any family members involved.
6. Complete additional questions regarding previous complaints made and whether this matter has been submitted to another agency or attorney.
7. On the reverse side of the form (or in an attached document), briefly describe your complaint. Ensure all relevant documents are included as photocopies.
8. Finally, read through the declaration before signing and dating the form at the bottom.

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