Form INS1007 "Pharmacy Benefit Manager Complaint" - Ohio

What Is Form INS1007?

This is a legal form that was released by the Ohio Department of Insurance - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2021;
  • The latest edition provided by the Ohio Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form INS1007 by clicking the link below or browse more documents and templates provided by the Ohio Department of Insurance.

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Download Form INS1007 "Pharmacy Benefit Manager Complaint" - Ohio

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Pharmacy Benefit Manager Complaint
Mike DeWine, Governor
Judith L. French, Director
Consumer Service Division, 50 W Town Street, 3rd Floor - Suite 300, Columbus OH 43215
Jon Husted, Lt Governor
614-644-2673 | 800-686-1526 | 614-644-3744 (Fax) | insurance.ohio.gov
Please note: This complaint form, all documents you send us, and any documents received by our office as a result of handling your
complaint may be a public record, subject to Ohio’s Public Records Act. This law requires all public records to be available for
inspection by anyone, upon request. WARNING: All documentation we receive will be imaged, and then destroyed. Make
copies of your documents and send the copies to us. Do not send original records.
If completing this form by hand, please use black or blue ink. DO NOT USE PENCIL.
Name:
Phone Number:
e-mail address:
Name of Pharmacy:
Address:
City:
State:
Zip:
County:
Name of Pharmacy Services Administration Organization (PSAO):
Name of Pharmacy Benefit Manager (PBM):
Name of Insurance Company:
Name or Number of Insurance Plan:
Type of Complaint (check one or more):
Appeals
Date of Appeal:
Licensure
Pricing (If you have multiple examples pertaining to one PBM, please attach document(s) containing any additional examples.)
Prescription (Rx) Number:
Product Name:
NDC:
Date of Service:
Other
Briefly describe your complaint. Please attach copies of all relevant documents.
(If you need more space, please attach additional sheets.)
How would you like to see your complaint resolved?
Please sign and date: To the best of my knowledge the above statement is correct. I understand that a copy of this form and any
attachments may be sent to the insurance company or agent involved. I authorize the insurance company to release all the medical
records relating to this complaint to the Ohio Department of Insurance, and I authorize the Ohio Department of Insurance to release
medical records relating to this complaint to the insurance company or agent as necessary in order to resolve this complaint. I
represent that I have the proper authority to execute this release.
Your Signature
Date
INS1007 (Rev. 02/2021)
Page 1 of 1
Pharmacy Benefit Manager Complaint
Mike DeWine, Governor
Judith L. French, Director
Consumer Service Division, 50 W Town Street, 3rd Floor - Suite 300, Columbus OH 43215
Jon Husted, Lt Governor
614-644-2673 | 800-686-1526 | 614-644-3744 (Fax) | insurance.ohio.gov
Please note: This complaint form, all documents you send us, and any documents received by our office as a result of handling your
complaint may be a public record, subject to Ohio’s Public Records Act. This law requires all public records to be available for
inspection by anyone, upon request. WARNING: All documentation we receive will be imaged, and then destroyed. Make
copies of your documents and send the copies to us. Do not send original records.
If completing this form by hand, please use black or blue ink. DO NOT USE PENCIL.
Name:
Phone Number:
e-mail address:
Name of Pharmacy:
Address:
City:
State:
Zip:
County:
Name of Pharmacy Services Administration Organization (PSAO):
Name of Pharmacy Benefit Manager (PBM):
Name of Insurance Company:
Name or Number of Insurance Plan:
Type of Complaint (check one or more):
Appeals
Date of Appeal:
Licensure
Pricing (If you have multiple examples pertaining to one PBM, please attach document(s) containing any additional examples.)
Prescription (Rx) Number:
Product Name:
NDC:
Date of Service:
Other
Briefly describe your complaint. Please attach copies of all relevant documents.
(If you need more space, please attach additional sheets.)
How would you like to see your complaint resolved?
Please sign and date: To the best of my knowledge the above statement is correct. I understand that a copy of this form and any
attachments may be sent to the insurance company or agent involved. I authorize the insurance company to release all the medical
records relating to this complaint to the Ohio Department of Insurance, and I authorize the Ohio Department of Insurance to release
medical records relating to this complaint to the insurance company or agent as necessary in order to resolve this complaint. I
represent that I have the proper authority to execute this release.
Your Signature
Date
INS1007 (Rev. 02/2021)
Page 1 of 1