HomeMy WebLinkAboutgrievance-or-appeal-request-form-english
GRIEVANCE or APPEAL REQUEST This form is used to file a Grievance or to request an Appeal. If you need assistance in completing this form, you can request help from your provider or by calling Consumer Assistance at (800) 779-0787. A signed Authorization for Release of Confidential
Information needs to be submitted along with this form. The Grievance or Appeal Request can be submitted to your provider (MD, case manager, clinician, the Program Supervisor, etc.) or mailed directly to Consumer Assistance at: 2000 Embarcadero Cove, Suite 400, Oakland, CA 94606. Please fill out both sides of this form.
I wish to file: (choose one) Grievance Appeal Check here if you are requesting that your Appeal be processed through the Expedited Appeals Process (see requirements for an Expedited Appeal)
Your address and phone number are important. We need this information to contact you about the outcome of your Grievance or Appeal. PLEASE PRINT:
Your Name:____________________________________________________________ Your Address:__________________________________________________________ Your Daytime Phone:___________________________ Date of Birth:___________
May we leave a message at the above #? Yes No Current Provider:________________________________________________________
If Applicable, Person Representing You:______________________________________ Their Address:__________________________________________________________
Their Daytime Phone:____________________________________________________
Page 2 of 2
Grievance Or Appeal Request Form-English
Please answer the following questions. Attach additional pages if needed. What is the problem? ____________________________________________________
______________________________________________________________________ ______________________________________________________________________
______________________________________________________________________ ______________________________________________________________________
What have you done to try to resolve the problem?_____________________________ ______________________________________________________________________ ______________________________________________________________________
______________________________________________________________________ ______________________________________________________________________
What would you like the solution to be? ______________________________________ ______________________________________________________________________
______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
___________________________________________ _____________________ Consumer (or Consumer’s Representative) Signature Date
You will not be subject to discrimination or any other penalty for filing a Grievance or Appeal. Your confidentiality will be protected at all times in
accordance with State and Federal law. You may request a State Fair Hearing
following the completion of the Appeal Process.