Member Care Form

  • 1. Your Information:

  • 2. Member or Party About Whom Complaint or Request is Made:

  • 3. Additional Parties Involved? (If so, fill out the following):

  • 4. Problem/Complaint:

  • 5. The Details:

  • 6. Your Desires/Expectations in Bringing this to Member Care:

  • 7. Is this an urgent/time sensitive matter? (If yes, explain)

  • Mediation Agreement

    Please read and initial below if your complaint is concerning a conflict or could potentially need mediation.
  • Please Initial Above
  • Date Format: MM slash DD slash YYYY