Potential Quality Issue Form

Please complete this form if you have a concern regarding the quality of health care performed by a TriWest provider. If you have a complaint regarding staff rudeness, cleanliness of office, wait time in office, discrimination, etc., please review the Complaint/Grievance Information .

This submission will go directly to the TriWest Clinical Quality Department for review within (1) business day.
Please be assured that TriWest takes all concerns seriously and will thoroughly investigate the matter and take all appropriate actions.

Following successful submission, only the tracking statuses of: New, In Progress, or Completed can be viewed within the secure portal. Due to Federal and/or state privacy regulations, we are unable to share any details, results or actions as a result of the investigation as it pertains to a clinical quality program.

Progress 0%Progress 0%

Beneficiary Information

Fields with an asterisk ( * ) are required.

Date of Submission

Beneficiary First and Last Name *

Beneficiary Date of Birth

Beneficiary Last 4 SSN *

Beneficiary Phone

Beneficiary Email

Please provide a valid email address.

Person Completing the Information

Please check if the person filling out this form is the Beneficiary.

First Name *

Last Name *

Phone *

Email *

Please provide a valid email address.

Relationship to Beneficiary *

Quality of Health Care Concern Information

Health Care Provider / Facility Name *

Date of Incident *

Select Quality Issue Type*

Describe Your Concern/Incident *

0 / 2000

Attach Documents if applicable. (Up to 5 attachments. Only .pdf file format. No larger than 25MB.)

DRAG & DROPto Upload

Beneficiary Information

Beneficiary First and Last Name *

Beneficiary Date of Birth

Beneficiary Last 4 SSN*

Beneficiary Phone*

Beneficiary Email

Person Completing the Information

First Name*

Last Name*

Phone*

Email*

Relationship to Beneficiary*

Quality of Health Care Concern Information

Health Care Provider/Facility Name *

Date of Incident*

Select Quality Issue Type

Describe Your Concern / Incident*

Attach Documents if applicable. (Up to 5 attachments. Only .pdf file format. No larger than 25MB.)

The Information collected with this form is subject to the Privacy Act of 1974 (5 U.S.C. 552A, as amended) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information shall be considered for official use only and protected accordingly. Any individual responsible for unauthorized disclosure or misuse of this information may be subject to a fine of up to $50,000 and/or other sanctions as appropriate.