Complaint Form
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Chinese PDF
Spanish (Español) PDF
- Fill out the Complaint Form by hand or on the computer.
- Print and sign the form.
- Fax or mail the Complaint Form and copies of any other needed records to:
HMO Help Center
Department of Managed Health Care
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
FAX: 1-916-255-5241
PDF
In order to use the form marked PDF, you must have Adobe Reader. This is a free software program. If you have Adobe Acrobat or Adobe Professional, you will also be able to use these forms. (PDF stands for Portable Document Format.)
If you click on the PDF link and you see a message that says error, you may not have the Adobe Reader on your computer. You can download Adobe Reader for free to your computer. Click on Adobe. You will be given directions on how to download the program.
If you have Adobe Reader, your computer will open the form. The form needs your signature. Fill in the blanks online, print the form, sign it and mail it to us.