GRIEVANCE FORM

Grievance Contact InformationGrievance Information
Description of GrievanceProvider Information(If Applicable)
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Grievance and Appeal Instructions

Please fill out the following form and be as complete as possible.

Additional languages available here.

(Fields marked

are REQUIRED)

Grievance Contact Information

The person submitting this grievance:
Patient
Patient Representative
Patient's Practitioner
Employer
Other (specify):

The person submitting this grievance-Contact Information:

Name:
Address:
City:	State:
Zip	Phone:

The Patient's Information:

Patient Name:
Patient ID:

Indicate Your Relationship To The Patient:

Grievance Information

Name of Health Plan:

Provider name and contact information of the person referenced in this
grievance.

Name:
Address:
City:	State:
Zip:	Phone:

Relationship To Patient:

Description of Grievance Please describe your grievance in as much detail as possible; include dates and names. We will notify you within five (5) calendar days of our receipt of the grievance. We will respond in writing within no more than 30 calendar days of our receipt.

Provider Information(If Applicable)

Please provide the name, address, and phone number of the provider
involved in this report:

Name:
Address:
Phone:

I attest that all of the information I completed above is true.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-800-428-6337 or for TTY/TDD services call 1-888-877-5379 (voice), or 1-888-877-5378 (TTY) and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.

If you believe your health coverage has been, or will be improperly cancelled, rescinded, or not renewed, you may also call the Department for assistance.

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