How to File a Grievance or Appeal

How to File a Grievance or Appeal

How to File a Discrimination Grievance

GRIEVANCE/APPEAL FORMS

Online Forms 

GRIEVANCE FORM - English (Online)

GRIEVANCE FORM - Spanish (Online)

APPEAL FORM - English (Online) 

APPEAL FORM - Spanish (Online)

Hard Copy Forms

GRIEVANCE/APPEAL FORM - English (Hard Copy)

GRIEVANCE/APPEAL FORM - Arabic ( Hard Copy)

GRIEVANCE/APPEAL FORM - Spanish (Hard Copy)

GRIEVANCE/APPEAL FORM - Vietnamese (Hard Copy)

GRIEVANCE/APPEAL FORM - Tagalog (Hard Copy)

GRIEVANCE/APPEAL FORM - Chinese (Hard Copy)

GRIEVANCE/APPEAL FORM - Farsi (Hard Copy) 

 

CMS Part C Coverage Reconsideration Request Form

CMS Part D Coverage Determination Request Form

Appointment of Representative Form (English)

Appointment of Representative Form (Spanish)

 

Your Rights - CommuniCare Advantage

Your Rights - Medi-Cal

Your Rights - Medi-Cal (Spanish)

Your Rights - Medi-cal (Arabic)

Your Rights - Medi-Cal (Vietnamese)

Your Rights - Medi-Cal (Tagalog)

Your Rigths - Medi-Cal (Chinese)

Your Rights - Medi-cal (Farsi)

 

Language Assistance Services