Grievance Form

Date: 2/22/2025

To Client/Enrollee:

The following is a Grievance Complaint Form that you may complete in order to expedite your complaint. If you need help in filling this form out, please call us at 1-800-367-7474 or 711 for CRS TTY users.

Name of Enrollee (if applicable):

Subscriber's name*:
(E.G., Employer's Name, University's Name, Company's Name)

Name of provider you have been seeing*:

State your complaint*:

By checking this box, I am filing this grievance and submitting a legal and valid signature. I understand that I'll be advised of any additional procedural and appeal rights to which I'm entitled as Empathia Pacific moves forward with my issue.

Type in your full name to sign this form*:

Date: 2/22/2025

Printed name*:

Phone*:

Address*:

City*:

State*:

Postal Code*:

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 1-800-367-7474 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 website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.

Language assistance services in your preferred spoken or written languages are available at no cost by calling 1-800-367-7474. Para solicitar servicios sin costo de asistencia en sus idiomas preferidos, orales o escritos, puede llamar al 1-800-367-7474.

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