Claims BureauNew York State Attorney General 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the 'CONSUMER Information' section. Fill in your name, home and work telephone numbers, street address, city/town, county, state, and zip code clearly.
3. In the 'COMPLAINT Information' section, provide details about the person or company you are complaining about. Include their address, city/town, state, zip code, and telephone number.
4. Specify the date(s) of service and the cost of service. Indicate how you paid for the service by checking the appropriate boxes.
5. Fill in your health plan's name and identification number. If applicable, provide details for any family members involved in the complaint.
6. Answer questions regarding previous complaints made to the individual or company and whether you filed a formal appeal or grievance with your health plan.
7. Describe your complaint on the reverse side of the form. Attach any relevant documents as instructed.
8. Finally, sign and date the form before submitting it to ensure all information is accurate.

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