You can use this form to file a complaint about our privacy policies, procedures and practices. You can also file a complaint if you don’t think we’ve complied with our Notice of Privacy Practices, or state and federal privacy rules and laws.

What you’ll need:

  • Your enrollee ID card
  • A printer to print the form
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number.

If you have any questions, please contact us.

Health Care Privacy Practices Complaint Form (PDF)