Date: __________

Your Name:

Office Address:

Office Phone #:

E-mail address (for communication about this problem only):

Prefer to be contacted by Magellan by: ____ e-mail ____ phone

Patient ID #:

Patient First Name:

Patient Date of Birth:

Insurance Carrier (e.g. CareFirst, Aetna):

Statement of the Problem (please include only enough detail so that someone reading this form will have sufficient information to act on the problem):

1. Email or fax completed form to Philip B. Dvoskin, M.D., MPS Managed Care Committee (We have been advised that a Release of Information from the patient is not necessary, however, you may want to obtain one nonetheless.)
2. email: pdvos@comcast.net  
3. fax: 410-760-9727 
4. The complaint form will be emailed/faxed to Magellan.
5. Magellan will contact you by phone or mail within 3 working days to acknowledge the complaint. Magellan will then respond to the complaint:

a. Within 10 business days for complaints that do not involve claims;

b. Within 30 calendar days for complaints regarding a claim payment issue.

6. Magellan will provide Dr. Dvoskin with a weekly status report.