California Managed Care Members Grievance Form printable pdf download

California Managed Care Members Grievance Form

Attention Medicare Advantage members – do not complete this form. Request the “California

Medicare Advantage 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 or prefer to

file this grievance orally please call your medical group or health plan customer service department at

the phone number on your health identification (ID) card. If you think that waiting for an answer from

your health plan will hurt your health 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.

______________________________________________________________________________

Revised 06/09

California Managed Care Members Grievance Form