Official routing
Do not guess the agency. Match the issue to the authority.
Patients often lose time by sending one emotional complaint everywhere. This guide separates facility, board, insurance, OCR, disability-access, external-review, and billing routes before a packet is sent.
Hospital, clinic, patient relations, or grievance office
A problem that happened inside a hospital, clinic, ER, specialist office, testing center, or health system and needs a written response or escalation path.
- Ask patient relations, the clinic manager, or the grievance office for the proper complaint/grievance process, reference number, response timeframe, and how to submit supporting documents securely.
- Facility process, communication breakdown, care coordination, discharge confusion, disrespect, missing follow-up, and internal review.
State medical board / professional licensing
A concern that appears to involve unsafe professional conduct, abandonment concern, prescribing-process concern, failure to follow up, documentation issue, or another matter the state board says it accepts.
- Use the FSMB directory to find the correct state board, then read that board's complaint instructions before drafting the packet.
- Professional licensing and conduct review for physicians or other licensed medical professionals, depending on the state board's jurisdiction.
State pharmacy board
Pharmacy access barriers, repeated refusal without clear explanation, transfer/fill communication problems, prescription-processing issues, or pharmacy conduct concerns.
- Use the NABP state-board directory, locate the correct board, and read the board's complaint instructions before sending private prescription information.
- Pharmacy/pharmacist licensing, pharmacy practice concerns, prescription-processing issues, and complaints the board says it accepts.
State insurance department / Consumer Assistance Program
Coverage denial, prior authorization problem, appeal-process issue, claim delay, confusing plan communication, or insurer complaint routing.
- Preserve the denial notice, appeal deadline, claim or authorization number, plan documents, call logs, and proof of prior attempts to resolve the issue.
- Insurance company or agent complaints, claim handling, denial handling, delays, plan communication, and consumer assistance where available.
External review after health-plan appeal
A plan denial that has gone through the internal appeal process and may be eligible for external review based on the denial notice and plan rules.
- Read the denial and appeal notice carefully, identify the deadline, and preserve the plan's instructions for external review.
- Outside independent review after an internal health-plan appeal is upheld, when the plan/process qualifies.
HHS OCR privacy, HIPAA, Part 2, or records privacy route
Record access, privacy, security, breach, HIPAA, Part 2, or medical-record handling concerns where OCR says its process applies.
- Identify the entity, date, acts or omissions, records involved, and whether this is an access/correction request, privacy complaint, or both.
- Federal health-information privacy complaints involving covered entities, business associates, and certain Part 2 records situations.
Civil rights, disability access, or discrimination route
Disability access barriers, effective communication problems, denied reasonable modifications, inaccessible health-care process, or discrimination concerns.
- Document the access barrier, requested accommodation or modification, response received, dates, location, witnesses if any, and the practical impact.
- Civil-rights complaint routes for covered health/social service programs, disability access issues, and possible discrimination depending on the setting.
Medical bill rights, surprise billing, or good-faith estimate dispute
A bill that does not match an estimate, possible surprise bill, missing itemized bill, financial-assistance issue, or collections concern.
- Preserve the bill date, estimate, explanation of benefits, itemized bill request, financial-assistance request, and any collection notice.
- Billing rights, No Surprises Act education, good-faith estimate dispute process, and medical-bill dispute routing where applicable.
