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Insurance Copay Complaint Form
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Insurance Copay Complaint Form

 
South Dakota Division of Insurance (SDDI)
South Dakota Department of Labor and Regulation
124 South Euclid Avenue, 2nd Floor
Pierre, SD 57501
Phone: 605.773.3563
Fax: 605.773.5369

This letter is to be used as a formal complaint notifying the SDDI that there is a discrepancy in the copayment amounts for Specialty office visits and Primary Care Physician office visits.


There is a South Dakota State law that states Specialty services may not be greater than the amounts expected for the services of a Primary Care Physician for the same or similar diagnosed condition. However, under the legal doctrine of preemption, Federal law can and does invalidate state law, therefore, state law does not apply.


With this in mind, we still have the right to voice our concerns and hopefully call attention to this issue and make a change for the positive. 


If you would like to send in a complaint; please print clearly with black ink, sign, date, and send to the above address.  


Patient Name: ___________________________________________________

Name of Insurance Company: _________________________________________

Name of Policy Holder (If other than patient): __________________________________


______________________________________________ _________________________
Signature of Patient/Policy Holder Date


Thank you for your consideration.

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