AHCA Logo
Español | Creole

Florida Medicaid Complaint Form

If you have a complaint about Medicaid Services, please complete the form below.

If you need help completing this form or prefer to speak to a Medicaid representative about your issue, please call toll free 1-877-254-1055; Telecommunications device for the deaf (TDD) 1-866-467-4970 to speak to a Medicaid representative.

* Required fields

For each complaint/issue, please provide:

Complainant Information
Your name
Your email  
Your phone number  
I am a *  
Who is the complaint/issue about?
Recipient Name (If different from above)
Recipient Gold Card, SSN, or Medicaid number
(If the issue pertains to more than one recipient, please include Gold Card, SSN, or Medicaid ID for each person in the Comment below, or upload in the Attachment section)
County *  
Have you previously submitted this issue, or a similar one, to the Agency? *  
What type of Managed Care Plan is this complaint/issue about? *  
What is the name of the Managed Care Plan? *  
Have you contacted the Plan about this issue? *  
Please complete all choices that relate to your issue:
 
Please select one of the 8 options highlighted below
I am a recipient and am having trouble obtaining the following service: *  
I am a new member and I have not received any plan information. If yes, check here: *  
I am having trouble finding a healthcare provider. If yes, check here : *  
I have questions about or need help with the plan complaint, grievance, appeal and/or Fair Hearing process. If yes, check here: *  
I have a complaint about my facility or its staff (Nursing Facility, Assisted Living Facility, Adult Family Care Home, Hospice). If yes, check here : *  
I am trying to enroll in a plan, disenroll from my plan or change my plan and need help. If yes, check here: *  
I am a Healthcare provider, and my complaint is about obtaining authorizations or claims payment issues. If yes, check here: *  
Other *  
Please describe in 2000 characters or less
 
Maximum file size allowed is 10 MB. Attach Supporting File:  
 




 

Your name, email and phone number are requested in case more information is needed to resolve your issue. If you wish to remain anonymous, you may omit this information. If you choose to send an issue anonymously, please provide as much detail as possible. Without enough detail, we may not be able to resolve your issue; however, your input is important and will be used to improve the program.

Thank you for completing this form. After you click the ‘Submit’ button above, a copy of your complaint will be sent to the email address that you provided.

Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public-records request, do not send electronic email to this entity. Instead, contact Recipient and Provider assistance by phone at 1-877-254-1055; Telecommunications device for the deaf (TDD) 1-866-467-4970.