Submit Complaint · Provider Portal

Please fill out the fields below and click 'Next' to move to the next step.

Complaint Number

Please enter your name

I am a(n)...

Please enter your Medicaid Number

Please enter your Member #, SSN, or Medicaid ID #

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Complainant Specialty

Agency Name

Alternate Complainant Name

Agency

Plan

Please Enter your Provider Medicaid Number

Please confirm your Provider number

Provider Alternate Complaint Name

Please confirm Medicaid number