Patient Issue Report Form for Michigan - write on line above description ______________________________________________________________________________ Medical Insurance - include employer and group number if applicable _______________________ _______________________ _______________________ Patient's Name Policy Holder's Name Medical Record Number _______________________ _______________________ _______________________ Street Address City State & zip code _______________________ ______________________ _______________________ Daytime Telephone No. Alternate Telephone No. Date of birth (patient) _______________________________________________ _______________________ Name of Person Filing Report (if not patient) Relationship to Patient _______________________________________________ _______________________ Location where issue/incident occurred Date of incident ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Please describe the nature of the issue - attach additional sheets if needed ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Please explain how you have tried to resolve this issue - attach additional sheets if needed ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ What would you consider a proper solution to this issue? - attach additional sheets if needed _______________________ _______________________ Signature Date Make three copies of the filled-in form and keep the original for your records. Distribute the three copies as follows: _____copy for chief administrator of the clinic or hospital where issue arose. _____copy for chief administrator of health insurance coverage. _____copy for Michigan Insurance Bureau, P. O. Box 30220, Lansing, MI 48909-7720 Form designed and distributed by MichUHCAN, 8846 Robindale, Detroit, MI 48239 Form available on the World Wide Web at http://michuhcan.tripod.com May be reproduced and used for free by anybody at any time.