Consumer Assistance Request Form

If this is a complaint against a healthcare provider, please fill out our Authorization for Release of Medical Information Form first and submit it along with your complaint using the "attach files" button below.

If this is a complaint against a credit card company, bank, credit union or financial institution, please fill out our Financial Authorization Form and submit it along with your complaint using the "attach files" button below.

Complaint Type

Language:

Your Name

First NameLast Name

Your Suffix

example: Jr., Sr., etc.

Your Company/Organization (if applicable)

Your Street Address

Your Street Address Line 2

Your City

Your State

Your Zip Code

Your Primary Phone

Your Alternate Phone

Your Email

Confirmation Emailexample@example.com

Name Company You Are Complaining About

Contact Person

Contact Person Title

Company Street Address

Company Street Address Line 2

Company City

Company State

Company Zip Code

Phone Number

Company Email

example@example.com

Have you contacted another agency?

Agency You Contacted

Result of Contacting Agency

Have you filed a lawsuit?

Court File No.

What was the result?

Product/Service Involved

Date of Purchase

Amount of Purchase ($ USD)

Customer ID or Account Number

Explanation of the Problem

What do you want the company to do?

Attachments

Attach Files

Max total size limitation: 10 MB. Accepted file types: pdf, doc, docx, xls, xlsx, csv, mp3, jpg, png,

By choosing Accept below, I consent to and acknowledge that the information I am providing may be used and/or disseminated by the Minnesota Attorney General’s Office: (a) to resolve the issue about which I am contacting the Office, including by contacting any person or entity complained against; (b) to communicate with me; (c) to other law enforcement agencies and/or consumer-assistance agencies; and (d) to otherwise assist in enforcing the law. Except as otherwise authorized by this consent, I understand that the information I am providing will be treated as “private data on individuals” under the Minnesota Government Data Practices Act, Minn. Stat. ch. 13, and shall not be used or disseminated except as authorized under the Act or other applicable state or federal law. I understand that I am not legally required to provide the information I have submitted in this form, but that my failure to do so may make it more difficult to resolve my concern.

Consumer Assistance Request Form

Your Information

Company Complained About

Other Information

Product, Service, or Payment Involved

Explanation & Resolution