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 Number.
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 original documents.
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 Email: heau@oag.state.md.us 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 appropriate.
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 be disclosed.
1-888-373-7888
233733
