Get Pbm Complaint Form - Mississippi Board Of Pharmacy

Filing a complaint with the Mississippi Board of Pharmacy is an important step in addressing issues with pharmacy benefit managers. This guide will help you navigate the process of completing the PBM Complaint Form online, ensuring you provide all necessary information clearly and accurately.

Follow the steps to complete the complaint form online.

1. Press the ‘Get Form’ button to obtain the PBM Complaint Form and open it in your preferred online editor.
2. Begin by providing the patient information. Fill in the name of the complainant, their relationship to the patient, the patient’s name, patient ID number, address, city, state, zip code, date of birth, email address, phone number, and cell phone number.
3. In the signature field, ensure the complainant provides their signature to validate the information submitted.
4. Next, move to the pharmacy information section. Enter the pharmacy name, license number, the pharmacist’s name, their license number, address, city, state, zip code, email address, business phone number, and cell phone number.
5. Have the pharmacy representative sign in the signature field to confirm the details provided.
6. Proceed to the pharmacy benefit manager (PBM) information section. Provide the PBM name, PBM plan code, contact name (if known), contact phone number, address, city, email address, PBM bin number, state, zip code, and business phone number.
7. Fill in the insurance information with the name of the insurance provider and the name (or number) of the insurance plan. Indicate if this is an ERISA plan by circling 'YES', 'NO', or 'I DON’T KNOW'.
8. In the details of the complaint section, describe the nature of the complaint. If necessary, attach additional documents that may support the complaint.
9. Review all the gathered information for accuracy and completeness. Save any changes you made, then download, print, or share the completed form as needed.

Complete your PBM Complaint Form online and take the necessary steps to address your concerns.