California Member Grievance

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About You

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Please identify yourself: Select Patient Patient’s Representative Treating Provider Employer Broker Other
Your Name:
Email Address:
Daytime Phone Number:	Evening Phone Number:
Street Address Line 1:	Street Address Line 2:
City :	State : Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip Code:

About the Member

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Your relationship with member: Select Self Patient’s Representative Treating Provider Employer Broker Other
Member ID (optional):
Member First Name:	Member Last Name:
Health Plan Name:

Grievance Information

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Explain your concern:

Please provide names, phone numbers, and addresses of other persons referenced in your grievance

Attachments

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Click on Upload button once file is selected!