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EYEXAM of California

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EYEXAM of California Inc.

GRIEVANCE FORM

Please complete the form below. Required fields are indicated with an asterisk (*).

Member Name   Mr   Mrs   Ms   Dr  
First *   MI   Last *  
Address *  
City *   State *   Zip *   (format nnnnn-nnnn)
Contact Method *     Telephone    Email
Type Of Membership *     Individual    Group
Group / Individual ID Number *  
 
Completing Form For *     Self    EYEXAM Member
Suggestion Or Complaint. *  Please include the details leading to your suggestion or complaint, such as the date, location and names of others involved:
 
By submitting this form, you acknowedge that you are the patient or the guardian/authorized representative of the above named complainant, and you are authorizing us to conduct an investigation of the facts set forth in the above complaint.
 
 
 

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 1-888-439-3392 and use your health plan's grievance process before contacting the Department. The Plan also has a TDD line 1-949-364-1289 for the hearing impaired. Utilizing 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.