Complete and sign this form if you filed a complaint or grievance with your health plan and:

• You are not satisfied with your plan's decision or
• You have not received your plan's decision within 30 days.

If you want to give another person the authority to assist you with your complaint, you must also complete the Authorized Assistant Form.

If your complaint is about a serious health risk, call the HMO Help Center now. Calls to these numbers are free.
(888) HMO-2219 / (888) 466-2219     TDD (877) 688-9891

First Name   Middle Initial   Last Name

Name of Parent or Guardian if Filing for Minor Child

Street Address

City   State   Zip

Daytime Phone #   Evening Phone #

Health Plan Name

Patient's Membership Number*   Patient's Date of Birth (mm/dd/yy)

Medical Group Name*   Medical Group Number*
*on your insurance card

Do you have Medi-Cal?	Yes   No
Do you have Medicare or Medicare Advantage?	Yes   No
Have you filed a complaint or grievance with your health plan?	Yes   No
Did your health plan cancel your insurance?	Yes   No

Please explain your complaint: (use a separate sheet if necessary)
            For example: What service did you want from your health plan, or provider?
What was wrong with the service you got from your health plan, or provider?
What billing problem do you have with your health plan, or provider?


 
What is your health problem related to this complaint?


 
What treatment(s) have you had for this health problem?


 
Please list the providers who have treated you for your health problem, if you have their names.


 
Have you filed another complaint about this problem?

With the HMO Help Center?	Complaint File # (if known)
With another government agency?	Complaint File # (if known)
Please list government agency:

Attach copies of documents related to your complaint, such as denials, letters, bills, and explanations of benefits. We cannot return originals.

I am asking the Department of Managed Health Care (DMHC) for a decision about my problem with my health plan. I understand that a copy of my complaint will be sent to my health plan. I allow my providers, past and present, and my health plan to release my medical records to the DMHC. These records may include medical, mental health, substance abuse, HIV, diagnostic imaging reports, and other records related to my case. These records may also include non-medical records and any other information related to my case. I allow the DMHC to review these records and information. My permission will end one year from the date below, except as allowed by law. For example, the law allows the DMHC to continue to use my information internally. I can end my permission sooner if I wish. All the information that I have provided on this sheet is true.

Patient or Parent Signature   Date

Print this form, sign it, then mail or fax this form and any attachments to: HMO Help Center, Department of Managed Health Care, Complaint Unit, 980 Ninth St., Suite 500, Sacramento, CA 95814; FAX: (916) 255-5241

If you want to give someone the authority to assist you in your Independent Medical Review (IMR) or complaint, fill in Parts A and B below.

If you are a parent or legal guardian filing this IMR or complaint for a child under the age of 18, you do not need to complete this form.

If you are filing this IMR or complaint for a patient who cannot complete this form and you have legal authority to act for this patient, please complete Part B only. Also send a copy of the power of attorney for health care decisions or other legal document that says you can make decisions for the patient.

I allow the person named below in Part B to assist me in my IMR or complaint filed with the Department of Managed Health Care (DMHC). I allow the DMHC and IMR staff to share information about my medical condition(s) and care with the person named below. This information may include mental health treatment, HIV treatment or testing, alcohol or drug treatment, or other health care information.

I understand that only information related to my IMR or complaint will be shared.

My approval of this assistance is voluntary and I have the right to end it. If I want to end it, I must do so in writing.

Patient or Parent Signature   Date

Name of Person Assisting (print)
Signature of Person Assisting
Address
Relationship to Patient
Daytime Phone #
Evening Phone #

My power of attorney for health care decisions or other legal document is attached.

California's Knox-Keene Act gives the Department of Managed Health Care (DMHC) the authority to regulate health plans and investigate the complaints of health plan members.

• The DMHC's HMO Help Center uses your personal information to investigate your problem with your health plan and to provide an Independent Medical Review if you qualify for one.
• You give us this information voluntarily. You do not have to give us this information.
• However, if you do not give us the information, we may not be able to investigate your complaint or provide an Independent Medical Review.
• We may share your personal information, as needed, with the health plan and the doctors who are doing the Independent Medical Review.
• We may also share your information with other government agencies as required or allowed by law.
• You have a right to see your personal information. To do this, contact the DMHC Records Request Coordinator, DMHC, Office of Legal Services, 980 Ninth Street, Suite 500, Sacramento, CA 95814-2725, (916) 322-6727.

* The law that requires this notice is the Information Practices Act of 1977 (California Civil Code Section 1798.17).

Print this form, sign it, then mail or fax this form and any attachments to: HMO Help Center, Department of Managed Health Care, Complaint Unit, 980 Ninth St., Suite 500, Sacramento, CA 95814; FAX: (916) 255-5241