GrievanceForm

Medi-Cal Grievance
(Complaint) Form

Section A: Member Information

Last Name

First Name

Initial

Date of Birth (MM/DD/YY)

Date of Incident

Mailing Address

City

State

Zip

Evening Phone Number

Daytime Phone Number

Contact Hours (Please specify when you prefer to be called)

Member Number

Section B: Please give a detailed reason for your grievance (complaint):

Section C: Signature

I certify that the statements made in this complaint are true and correct to the best of my information and belief

Signature

Date

If the complaint is filed by a personal representative on behalf of the individual, complete the following and check the appropriate box.
Print Name of Personal Representative:

Signature of Personal Representative

Date

Parent of Minor Child Legal Guardian Power of Attorney Executor/Conservator

Other

Please return this form to:

Molina Healthcare of California

Attn: Member Appeals and Grievance

200 Oceangate, Suite 100

Long Beach, CA 90802 or

Fax (562) 499-0757

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at , TTY users dial 711 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.

You can ask for help from the Department of Health Care Services (DHCS). The DHCS can help Medi-Cal Managed Care members with grievances and appeals. If you want to contact the DHCS to talk about your concerns, problems, or complaints, please call the Medi-Cal Managed Care Ombudsman toll-free at 1-888-452-8609, Monday through Friday between 8:00a.m. and 5:00 p.m. TTY users can dial 711