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Insurance Complaint Form

Insurance Complaint Form

If you are having issues with any insurance company, managed care network or TPA please let us know. The KAC needs a comprehensive file of insurance complaints, allegations, and issues from across the state to use at Complaint and Resolution meetings we are having with The Department of Insurance, Medicaid, Medicare, Workers’ Compensation Board, and with offending Insurance Companies.  We must have facts to demonstrate the problems….facts that only you can provide.  

Click the link below to download and fill out a Insurance Complaint Form. Please attach any supporting sanitized documentation (such as EOB or Denial Letter). Please remove ALL patient identifying information so you can remain HIPPA compliant.

Fax, email or mail the complaint forms and any sanitized supporting documentation to the KAC executive office.        

KAC Internal Insurance Complaint Form 

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