Sample Grievance Letter printable pdf download

Sample Grievance Letter

The words that are slanted are directions.

GRIEVANCE

Your Member ID Number

Your Name

Your Address

Your Town, State and Zip Code

Name of HMO

Address of HMO

Town, State and Zip Code of HMO

Dear Grievance Specialist,

Today’s Date

I am writing to file a grievance with Name of HMO. I am having a problem

with PCP, medical treatment, home health care or other problem. I am submitting

this letter as a (pick one) GRIEVANCE/ EMERGENCY GRIEVANCE because I do not

agree with the decision about my care, I do not like the way I was treated,(or any

other problems).

My HMO ID number is __________________________. My ACCESS card number is

________________________. My Primary Care Provider (PCP) is

___________________________.

Begin your description here. Write about the steps that led up to the

problem. In include facts like appointment dates, times and provider’s names and

people who you spoke with. Tell them how you want the problem fixed. Be clear

about everything that happened.

I expect a response to my grievance within 30 days in writing (48 hours if it

is an emergency grievance). Please send all information to me at the above

address. Also send a copy to the name and address of an agency or person that

is helping you like your PCP or an advocate.

Sincerely,

Sign your name

Print your name

Cc: Name of anyone else you are sending the letter to

Sample Grievance Letter

Sample Grievance Letter