Complaint Resolution Form "*" indicates required fields Complainant Name* First Last Complainant Phone*Complainant Email Member Name* First Last Complaint Type*Missed TripProvider ComplaintGas ReimbursmentMediTrans EmployeeOtherMedicaid IDComplaint Info*Date of Issue* MM slash DD slash YYYY Warm Transferred to Health Plan?* Yes No Health Plan*Aetna Better HealthAmeriHealth CaritasAnthem Medicare AdvantageHealthy BlueHumanaLouisiana Healthcare ConnectionsAgent Name* First Last
