Enrollee Complaints Form
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1United Health Care International Ltd
ENROLEE COMPLAINTS FORM
Please fill-out the following portions regarding our service or care experience with which you are
not pleased.
Our Policy regarding Grievances
We take the reporting of your dissatisfaction most seriously as it is one sure means through
which we can offer you better services. Your complaints will be treated confidentially and would
not negatively affect our future services to you. We therefore welcome your sincere report and
would, without delay look into it and then get back to you.
Expect to receive a feedback (even if preliminary) from our office within 72 hours of receiving
your complaints.
Date of filing grievance___/___/___
Personal Data
Name ________________ ________________ ________________
Surname
First name
Middle name
Telephone number (Mobile) _____________ (Office) ___________
(Home) _________________Email __________________________
Enrolee Number _______________Type of Plan ______________
If under a company or employer group, please state:
______________________________________________________
Your complaints relate to which of the followings? (Please tick)
□
Care at the Clinics/Hospital
□
Pharmacy Service
□
Investigations or Tests at the laboratory
□
Services directly provided by the HMO office
Please state detailed summary of your complaint
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Please use additional sheet if required.
Which of the followings most closely describe how you feel with the service you received?
I feel the HMO/Hospital/Clinics could have done a little better
□
I feel the service is bad
□
For Office Use
I feel the service is very bad
□
Date received __/__/__
I feel the service terribly bad
□
Time________
I feel seriously disgusted with the awful service
□
Processed by _____________
Signature _______________________
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Parent category: Legal