Grievance Policy Notice

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5234 Chesebro Road, Suite 201
Agoura Hills, CA 91301
(800) 367-7474 • Fax (818) 707-0496
Grievance Complaint Form

To: EAP Client/Enrollee:

The following is a grievance form to submit a written expression of dissatisfaction regarding any aspect of Empathia's services. This form does not have to be completed to submit a complaint. Grievances may be submitted by telephone to any of Empathia's toll-free numbers or face to face at an Empathia provider office location. Neither Empathia nor any of its providers will discriminate against a Member based on the filing of a grievance.

The Member Services Officer and Clinical Director will review and investigate all grievances. By law, all grievances must be resolved within 30 days of receipt. If a grievance is not resolved within 24 hours, the Member will receive a letter acknowledging receipt of the grievance and a letter summarizing the disposition upon resolution.

If you need help in filling this form out, please call us at 1-800-367-7474.

To email us the form, please fill out the form below.

*Required Field

Employer [Group] Name:*
Name of EAP Provider You Have Been Seeing:*
State Your Complaint:
Name of Employee (if applicable):

"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- HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site has complaint forms, IMR application forms and instructions online."

Language assistance services in your preferred spoken or written language are available at no cost to you by calling 1-800-367-7474. The Plan provides interpretation services, translation of grievance forms, and a TTY line at no cost to enrollees.