Insurance Incident Form
Oregon LAcs, this is form is to help the OAAOM gather useful provider complaints/experiences for our ongoing meetings with management at Regence Blue Cross Blu Shield, MODA and other groups. While you should always submit a complaint to the provider relations rep (and potentially the Oregon insurance division!) this form will help us gather complaints over time and provide accurate and useful data for reform of provider experience. Thanks for telling us your story!
Please list the insurance carrier or other relevant plan details here.
Please list the nature of the complaint(s). Check all that may apply.
Tell us any additional details about your story, especially a claim #, date of the incident or names of any reps you spoke with. DO NOT SHARE PATIENT IDENTIFIABLE INFORMATION.
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