Grievance Form

Member's Information

Member's Name ! Date of Birth (mm/dd/yy) !

Member's Address !

City ! State ! Zip Code !

Phone !

Member's Plan ID Number !

Are you the Member? !

Yes

Complete the following section ONLY if the person making this request is not the member:

Requestor's Information

Requestor's Name !
Requestor's Relationship to Member !
Address !
City ! State ! Zip Code !
Phone !

Attach documentation showing the authority to represent the member if it was not submitted previously. Representatives include family members, friends, caregivers or providers; that the member authorized in writing; or others legally able to act on behalf of the member such as someone who holds power of attorney or the member’s legal guardian.

Grievance Details

Date Grievance happened (mm/dd/yy)
If Applicable, Date of the notice of denial you received
Grievance Description:

Important Note: Expedited Decisions

If you or your provider believe that waiting 30 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your provider indicates that waiting 30 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your provider’s support for an expedited appeal, we will decide if your case requires a fast decision.

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS If you have a supporting statement from your provider, attach it to this request.

FILING A COMPLAINT WITH THE CALIFORNIA DEPARTMENT OF MANAGED HEALTH CARE (DMHC)

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 1-855-772-9076 (TTY 711) 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-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s Internet Web site www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.

Signature of person requesting the grievance:

Signature ! Signature Type
Date: