Grievance Form For California Managed Care Members

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Grievance Form for California Managed Care Members
Attention Medicare + Choice members – do not complete this form. Request the
“California Medicare + Choice Plan Member Appeal and Grievance Form”
You have the right to file a grievance about any of your medical care or service. If you want to
file a grievance, please use this form. There is a process you need to follow to file a grievance.
Your health plan must, by law, give you an answer within 30 days. If you have any questions,
please feel free to call your doctor’s office or health plan at the phone numbers on the back of
this form. You may also call the phone numbers on your health identification (ID) card. If you
think that waiting for an answer from your health plan will hurt your health, call and ask for an
“Expedited Review.”
Please print or type the following information:
_________________________________________________________________________________
Member Name (Last, first, middle initial)
___________________________________________ _____________________________________
Address
Home Phone number (include area code)
__________________________________________
______________________________________
City, State, Zip
Work Phone number (include area code)
__________________________________________
______________________________________
Name of Employer or Group
Enrollment or Member ID #
__________________________________________
Date of Birth
If someone other than the member is filing this grievance, please provide the following
information:
Name:
Daytime Telephone #
__________________________________
________________________
Relationship to Member:
________________________________________________________________
Address: __________________________________________________________________
City: ____________________________ State: _________ Zip: ______________________
Write what your grievance is about. Give dates, times, people’s names, places, etc. that are
involved.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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