Member Grievance Form

Please complete the following information and click the Preview button below.

Should you wish to contact us by telephone regarding your gievance, you may call us at any time during normal business hours at (800) 870-5857 or at any of our offices. Whether your submission is by web, in writing, in person, or by phone, we will respond to you in writing within 5 calendar days of the date of your complaint. You may also print out this form and return it to any of our offices.

* The following areas are required to complete your request.


Member Information

Member ID:
*Member's
Last Name:
*Member's
First Name:
E-Mail Address:

(In case we need to contact you by phone)
Day Phone:
*Address:
*City:
*State:
*ZIP Code:
 

*Date of Incident: (mm/dd/yyyy)

*Please explain your grievance (include all relevant details and personnel involved):


What might Vision First Eye Care do to increase your satisfaction?



 

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 (800) 870-5857 or (408) 923-0400 and use your health plan's grievance process before contacting the department. Utilitzing 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 http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.  

 

 

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