UCare Provider #:  
NPI #:  
Clinic Name (Group):  
Clinic Contact:  
Phone #:  
Address:  
City:  
State:  
Zip:   -
Reporting Year:  
Reporting Quarter:  
Your E-Mail Address:  
   
COMPLAINT INFORMATION
(Multiple complaints can be entered; click the Add Complaint Information button after each complaint)
Date Complaint Received (From Member) :    ...
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Date of Resolution:    ...
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Member Information
First Name:
Last Name:  
Date of Birth:    ...
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Type of Complaint: May Check more than one issue per complaint
   




Brief Summary of Complaint:  
Summary of Issue/Resolution:
   
Brief Summary of Resolution: