Member Services Complaint/Grievance

Select one of the following
Select one of the following
- Member Complaint
- Member Complaint - Adding Additional Information
- Member Grievance
Complete the following form when the member expresses dissatisfaction and they wishes to file a complaint.
Complete the following form when the member expresses dissatisfaction with the outcome of a complaint and the member wishes to file a grievance.
Member Information
Member's ID#(Required)
Member's Date of Birth(Required)
MM slash DD slash YYYY
Member's Name(Required)
First Last
Error
Plan Name(Required)
Original Issue ID
Representative Information
Name of the person filing the complaint (if not the member)
Verbal Consent Obtained?(Required)
Verbal Consent Obtained? *
- Yes
- No
Member Complaint Information
Date of when the Complaint was filed(Required)
MM slash DD slash YYYY
Time of Complaint(Required)
Date of the Incident
MM slash DD slash YYYY

(approximate date)
Is Member Complaint Against Neighborhood?(Required)
Is Member Complaint Against Neighborhood? *
- Yes
- No
NHPRI Staff Name (if applicable)
Is Member Complaint Against a Provider or Pharmacy?(Required)
Is Member Complaint Against a Provider or Pharmacy? *
- Yes
- No
Provider or Facility Name/Pharmacy Name(Required)
Provider NPI Number (Enter for Medical Provider)
Provider Name
Error Message
Staff Name (If applicable)
Supplier NPI Number (Enter for Medical Provider)
Supplier Name
Error Message
Provider or Facility Address/Pharmacy Address(Required)
Street Address Address Line 2 City State ZIP Code
Provider or Facility Phone Number/Pharmacy Phone(Required)
Detailed description of the complaint: What is the members main complaint?(Required)
How did you attempt to resolve the issue before offering a complaint?(Required)
Member Services Representative Information
Name(Required)
First Last
Email(Required)
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Member Information

Representative Information

Member Complaint Information

Member Services Representative Information