Print the Authorized
Representative Form. Please fill out Boxes 9-16, sign and date
the form and return the form to us.We need this
release form in order to proceed on your behalf.
Fill out the Complaint Form HERE. When your
information is complete; click the "Submit" button.
You will receive a notice that your complaint has been submitted for
processing and you will be provided with a Complaint Submission number. You will
be able to print your complaint from this screen. You will receive an email
within 2-3 business days with your HEAU Complaint number.
Send the following documents to our office via mail, email or fax:
The first page of your Complaint with the Complaint Submission
A signed and dated Authorized Representative Form.
Copies of any documents relevant to your complaint.
If your complaint is about Advanced Premium Tax Credits or Cost-Sharing
Reductions, we will need copies of financial records that show your household
income (paystubs, W-2 forms, wage and tax statements). Please do not send
Office of the Attorney General, Health Education and Advocacy
Unit200 St. Paul Place, 16th FloorBaltimore, MD 21202(410)
528-1840FAX (410) 576-6571Toll-free in Maryland1-877-261-8807
Receipt of the Authorized Representative Form and copies of other documents
relevant to your complaint are necessary to begin the mediation
process.IMPORTANT: You only have 90 days from the date of
the Maryland Health Connection notice to ask for a hearing. It is very important
to provide us your documents as soon as possible.
1. The HEAU can help you file your appeal and can negotiate with Maryland
Health Connection on your behalf prior to your hearing. Unfortunately, if your
case proceeds to a hearing, the HEAU cannot represent you at that hearing.
2. A copy of the complaint form and any documents you provide us may be sent
to Maryland Health Connection and their authorized agents. If your complaint
should be referred to another State or Federal agency (ex. Maryland Insurance
Administration, Department of Health and Mental Hygiene) we will forward your
complaint to that agency. By filing a complaint with our office you are
authorizing us to forward your complaint to another State or Federal agency, if
3. Complaints submitted to our office become matters of public record;
however, all or part of the complaint may remain confidential as required or
permitted by Maryland's public records law. For example, in health care-related
complaints filed with our office, medical or psychological information about an
individual will not be disclosed to the public. Financial information will not
200 St. Paul Place, Baltimore, MD 21202
410-576-6300 / En español 410-230-1712 / 1-888-743-0023 toll-free / TDD: 410-576-6372