Potential Quality Issue Form

If you previously submitted a PQI form, navigate to the PQI Status.

Complete this form if you have a concern regarding the quality of health care services performed by a TriWest provider. The submission will go directly to the TriWest Clinical Quality Department for review within one (1) business day.

After submitting the Potential Quality Issue form (PQI), the following statuses can be viewed in the portal: New, In Progress, or Completed. Due to Federal and/state privacy regulations, no PQI details, results, or actions resulting from investigations pertaining to the clinical quality program will be shared. Please be assured that TriWest takes all concerns seriously and thoroughly investigates matters and takes all appropriate actions.

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Fields with an asterisk ( * ) are required.

Date of Submission

Beneficiary Information

Beneficiary First and Last Name *

Beneficiary Date of Birth

Beneficiary Last 4 SSN *

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

Person Completing the Form

First Name *

Last Name *

Phone *

Email *

Relationship to Beneficiary *

Quality of Health Care Concern Information

If you do not know any of the provider information below, try our provider search.

Provider/Service Location Name *

Provider/Service Location Address *

Provider NPI *

Date of Incident *

Issue Type*

Describe Your Concern/Incident *

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Attach Documents if applicable. (Up to 5 attachments. Formats accepted are .doc, .docx, .jpg, .pdf, .png, .tif, .xls, or .xlsx no larger than 25MB per file)

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Beneficiary Information

Beneficiary First and Last Name *

Beneficiary Date of Birth

Beneficiary Last 4 SSN*

Person Completing the Form

First Name*

Last Name*

Phone*

Email*

Relationship to Beneficiary*

Quality of Health Care Concern Information

Provider/Service Location Name *

Provider/Service Location Address *

Provider NPI *

Date of Incident*

Issue Type

Describe Your Concern / Incident*

Attach Documents if applicable. (Up to 5 attachments. Formats accepted are .doc, .docx, .jpg, .pdf, .png, .tif, .xls, or .xlsx no larger than 25MB per file)

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.