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Patient Grievance Form

Please complete this form to submit complaints relating to services, personnel, provider offices or any other aspect of your plan that affects you as a participant.

Employee Name: (Last, First MI)
Patient Name (Last, First MI): (Last, First MI)
Street Address: (optional)
E-mail Address: (optional)
Employee ID# or SS#:
Telephone Number: (###-###-####)
Name of Employer/Group:
Provider Name:
Provider Location:
Date of Service: MM/DD/YYYY

Please describe your complaint. Include the details leading to your complaint, name(s) of others involved, and any related documents/receipts.

If you are completing this form on behalf of the patient, please provide the following information.

Name:
Relationship to Patient:
Address:
Daytime Telephone #: ###-###-####

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 800-877-6372 , 714-619-4660 , or for TTY/TDD access for the hearing and/or speech impaired 877-735-2929 and use your health plan's grievance process before contact 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 and emergency, a grievance that has not been satisfactorily resolved by your 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 888-HMO-2219 (888-466-2219) and a TDD line at 877-688-9891 for the hearing and speech impaired. The department's Internet website (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms, and instructions online.