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Grievance or appeal form

I want to report a grievance or appeal

1. Grievance details

Please provide details of the grievance or appeal in the fields below. All fields marked with an asterisk (*) are required.  


*Check the one that applies
Date of incident or notice of denial received
Please provide a description of your grievance or appeal.

2. Member information

Please provide the following information. All fields marked with an asterisk (*) are required.

Example: 12345
Example: 1234567890
*Are you filing this grievance or appeal on behalf of someone else?


Important note: Expedited decision


If you or your provider believes our standard time frame of 30 days to make a decision on your appeal will seriously jeopardize your life or health, you can ask for an expedited appeal.

Today's date

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