Member Submitted Provider Report
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Welcome to the Member Submitted Provider Report page. Here you can tell us about your experience with
providers using the EquityHealth program. We want to know it all, the good bad and the ugly, so do not hold back.

Please fill in all fields. The more information we have; The better we can profile providers and tell other members
about your experience. Incomplete data will not generate a completed report.

Thank You for taking The time to report on your provider
Provider Report Submission Form
* Required Field
Your Member Number:
*
*
 Email:
Provider Name
*
Provider Address
*
Date of your visit
*
Please rate your overall expirence with this provider
4
2
1
 3
 5
Average
 Great
Not Good
*
 Detail your report here