UCare Provider #:

NPI #:

Clinic Name (Group):

Clinic Contact:

Phone #:

Address:

City:

State:

Zip:

Reporting Year:

Reporting Quarter:

Your E-Mail Address:

Check here, if there are no Issues or Complaints for the quarter stated above.

COMPLAINT INFORMATION
(Multiple complaints can be entered; click the Add Complaint Information button after each complaint)

Date Complaint Received (From Member) :

(MM/DD/YYYY)

Date of Resolution:

(MM/DD/YYYY)

Member Information

First Name:

Last Name:

Date of Birth:

(MM/DD/YYYY)

Type of Complaint: May Check more than one issue per complaint

Brief Summary of Complaint:

Summary of Issue/Resolution:

Written

Verbal

Brief Summary of Resolution: