Member Grievance Form

Last Name:
First Name:
Middle:

Address:
Telephone:

City:
State:
Zip Code:

Member ID:
Date of Birth:
Sex:

Grievance

1. Where did the problem happen? (Name of hospital, doctor office or other location)

2. When did this happen? (Include date)

3. Who was involved?

4. Please describe what happened:

5. Have you made an attempt to resolve this problem?


If "Yes", please explain:

6. What would you like to see done about this problem?

7. Will you require language assistance?


 

If you selected Yes, what language do you speak?


If you have additional information or documents to submit, please fax them to (209) 461-2550 – Attn: Grievances or mail them to:

Health Plan of San Joaquin
Attn: Grievances
7751 S. Manthey Rd.
French Camp, CA 95231

I authorize Health Plan of San Joaquin to obtain medical records, claims information and other named data for the purpose of resolving a grievance on my behalf.

I understand that Health Plan of San Joaquin will propose a resolution to me within 30 days of receipt of this grievance. I understand that my cooperation is voluntary; however, failure to cooperate could have an effect on my grievance. I understand that my Evidence of Coverage booklet has a complete description of the grievance process and my rights.

Signature (type your name):
Date:


Did someone help you complete this form?


 

If "Yes", please complete the below, and please complete the authorization for the Use and Disclosure of Health Information Form:

Name:

Relationship:


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Signature:

Date: