Date of Report -- mm/dd/yy

Person completing this form:

Consumer/family member	Advocate
Social worker	Psychologist
Physician	Other (specify):
Nurse/nurse practitioner

Patient's Date of Birth:  -- mm/dd/yy

Patient's Gender:  Male    Female

Insurance Source (for self and family):

Private purchase	Medicaid
Employer	Medicare
Union

Name of Managed Care Company:

Whom have you sought help from with this managed care problem? Check all that apply:

Member services	Doctor
Social worker	Psychologist/psychiatrist
Advocate	Employer personnel department
Attorney	Nowhere
Case manager	Nurse
Other (specify):

Have you used the managed care company's internal grievance procedures? Yes  No

Grievance procedure results were:

in my favor  not favorable to me

Optional Information of the person completing this form:

Name
Phone
Address
City
State	Zip

 
Briefly describe the managed care problem:

Please check all of the statements that apply to your situation.

	1.	General problems with enrollment
	2.	Misleading marketing
	3.	Benefit package was not fully explained to me when I enrolled in the plan
	4.	Could not get a list of benefits covered by my plan
	5.	Received no notification of a change in how to access benefits
	6.	The managed care organization failed to give me the list of providers
	7.	At time of enrollment I did not understand that benefits are received only if the company approved the treatment, equipment, or service
	8.	At the time of enrollment I did not understand that I had to change doctors in order to receive full benefits
	9.	Received no notification of reorganization of provider panels and that my provider was  no longer with this managed care company
	10.	Providers I was given by the managed care company were very far away from where I live
	11.	Managed care company refused to approve a provider of my choice who was listed on its panel because the office was a distance from my home
	12.	Was denied the right to change my health/mental health care provider
	13.	Was not allowed to disenroll from the plan

	1.	Could not get through on the phone to the managed care company
Denied care
	2.	Denied adequate number of visits
	3.	Denied access to specialist
	4.	Denied continued mental health treatment unless I agreed to an evaluation by a psychiatrist and to take medication if prescribed
	5.	Denied approval for special medical equipment
	6.	Hospital stay denied (either before or after the admission)
	7.	Chose this plan because of the extensive mental health benefits but the company would not authorize my or my family's use of them
	8.	Company continued to refuse to pay for my medical care, even after going through their appeals process
	9.	Requested professional help because of how badly I felt and the person on the phone said that I did not need it
	10.	Representative of the managed care company asked lots of personal questions when I requested a referral to a mental health specialist
Delayed care (At the end of each statement, please state length of the delay)
	11.	Long wait for first appointment with primary care physician
	12.	Long wait for specialty care appointment
	13.	Long wait for follow-up appointment with primary or specialty provider
	14.	Delayed approval for special medical equipment

	1.	Managed care company did not supply me with a provider of the gender I had requested
	2.	Managed care company did not supply me with a provider who spoke my language
	3.	Waited in office for more than one hour to be seen
	4.	Specialist or sub-specialist who could best treat my condition was not available through the plan
	5.	Managed Care Company did not pay for the medication my doctor prescribed
	6.	Lost my health/mental health provider (social worker, psychologist, doctor, nurse, etc.), or dentist because my employer changed insurance plans

	1.	Have not been reimbursed for covered services for which I paid
	2.	It took months to receive my reimbursement

	1.	Managed care company insisted I turn over all case records to document service delivered
	2.	Managed care company demanded more information than was necessary to determine need for care
	3.	My determination of appropriate treatment and that of the managed care company were in disagreement
	4.	Mental health benefits were being micro managed to the point of interfering with treatment
	5.	Did not receive a decision regarding treatment in a timely fashion
	6.	Managed care company recommended self-help group for patient/family instead of health/mental health treatment
	7.	Managed care company did not approve medically necessary course of treatment most suitable to patient's diagnosis
	8.	Managed care company refused to reimburse either all or part of an in-patient hospital stay

	1.	Could not get through on the telephone to the managed care company
	2.	Have not yet gotten paid for services delivered
	3.	It took months to receive payment for services rendered
	4.	Was dropped from the provider panel without an explanation
	5.	Fees were summarily reduced
	6.	Was dropped from the panel because I am a solo practitioner
	7.	Managed care company reorganized panel and I was no longer the provider for patients already under my care