Please complete the form below and select submit to send your complaint.  The information will be sent securely to protect your privacy. Use the web browser print function if you would like to print a copy of this form for your records.

* Indicates a required field.


Name of Member filing the complaint:

First Name*
Middle Name
Last Name*
MVP Member ID Number*
Date of Birth (MM/DD/YYYY)*
Member Plan Type (If known):
Address*
City*
State*
Zip*
Phone Number*
Email Address*
 

Delegated entity/Alternate contact (If individual other than member is completing the information, then proper delegation for an alternate contact is required before MVP can investigate a complaint or release information):
First Name
Middle Name
Last Name
Address
City
State
Zip
Phone Number
Email Address:
Relationship to Member
 

Please check the basis for your discrimination complaint (Check all that apply):
 Race (specify): 
 Color (specify):: 
 National Origin (specify):: 
 Sex(specify):: 
 Disability(specify):: 
 Age(specify):: 
 Retaliation(specify):: 
 
Date of Alleged Discrimination (MM/DD/YYYY)* (your complaint must be submitted within 60 calendar days from the date of the alleged discrimination):

 

Detailed Description of Alleged Discrimination: (If individual other than member is completing the information, then proper delegation for an alternate contact is required before MVP can investigate a complaint or release information) (5000 Character Limit)
 
What relief or remedy are you seeking?*
Have you filed your complaint elsewhere?*  Yes    No
If Yes:  
Agency:
Date Filed: 
Case #:
Results/Findings:
Do you need any special accommodations for us to communicate with you about this complaint? (If yes, please describe)
Signature of member/Delegated entity/Alternate contact:
Date Form Submitted (MM/DD/YYYY):

MVP takes allegations of discrimination seriously.  We will contact you if more information is needed and you can expect a written decision within 30 calendar days of the date MVP receives this form with all the necessary information.  Your complaint must be submitted within 60 calendar days of the alleged discrimination.

 
 

 


  

Note: We may need to contact you for additional information to support your request.

 

MVP Health Care, Anti-Discrimination per Section 1557 of the Affordable Care Act 2016

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