Managed Care Settlements

You can submit this form electronically or click here to submit a hardcopy by fax or mail.

HEALTHNET PHYSICIAN GROUP AND PHYSICIAN ORGANIZATION SETTLEMENT COMPLIANCE DISPUTE CLAIM FORM

The undersigned hereby declares that he or she is a Class Member and did not Opt-Out of the Health Net Physician, Physician Group and Physician Organization Settlement Agreement.

Name
Address
City, State, and Zip Code
Tax Identification Number
Health Net Provider Number (if applicable)
E-mail address
Telephone Number
Signature
(Re-type name to indicate signature)
Date

Check one of the following:
I am bringing this Compliance Dispute on my own behalf.
I hereby authorize the following Signatory Medical Society to bring this Compliance Dispute on my behalf: 

Set forth in detail below, using particularized facts, the specific obligation(s) of Health Net to you under Section 7 of the Settlement Agreement which you allege Health Net has materially failed to perform. Describe how you have been adversely affected by Health Nets alleged failure to comply with those specific obligation(s). You may attach supporting materials or affidavit testimony.

In Order to allege a valid Compliance Dispute you must complete and return this form no later than 90 days after the Compliance Dispute first arose. For complaints submitted via First Class mail, send to:

Compliance Dispute Facilitator
Cameron C. Staples
Neubert, Pepe & Monteith, P.C.
195 Church Street, 13th Floor
New Haven, CT 06510
Telephone: 203-821-2000
Fax: 203-821-2009

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Located in New Haven and Fairfield, our law firm serves clients across Connecticut, including New Haven County, Fairfield County, Hartford County, and the communities of New Haven, Fairfield, Southport, Waterbury, Hartford, Bridgeport, Stamford, Norwalk, Danbury, Middletown, and New London.

Disclaimer: The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for advice regarding your individual situation. We invite you to contact us and welcome your calls, letters and electronic mail. Contacting us does not create an attorney-client relationship. Please do not send any confidential information to us until such time as an attorney-client relationship has been established.