Complaint/Grievance
If you are not satisfied with any aspect of your contact with ABHP or its representatives, please complete this form. If applicable, please provide the name, address, and phone number of the physician or provider involved in this report. Please describe your complaint in as much detail as possible; include dates and names. We will acknowledge your complaint in writing within 5 days and respond to your complaint with a resolution within 30 days.
Complaint / Grievance Submission Form
Patient's Name: (Required)Patient's Address: (Required)
Relationship to Subscriber. Enter 'Self' if applicable: (Required)
Patient SSN: (Required)
Describe Subscriber's Complaint/Grievance: (Required)
If other than patient, Name, Address and Phone Number or Email of person completing this form.
Name:
Address:
Phone:
Email: