Grievance or Complaint

This form is for 2023 requests only.
To submit a grievance or complaint for 2024, you can do so through your member website.

Please complete the fields below to submit an online request for a medical or prescription drug grievance or complaint. Fields marked with an asterisk (*) are required.

If you need assistance submitting this form, call provider services at 504-849-4688 or 877-346-5703.

1Please enter your information below.

2Please confirm the form data is correct and click submit.

Member's Information
Name*
First Last
Date of Birth*
Month
Day
Year
Member's plan ID*
Requestor's Information
Complete this section only if the person making the request is not the member.
Name
First Last
Your relationship to the member
Address
Street Address City State ZIP / Postal Code
Phone
Grievance or Complaint
Please be as specific as possible:*
Email: Please enter your email address below to receive a confirmation of your online request.*
Enter Email Confirm Email