CONSUMER COMPLAINT FORM


Complete, Print, Sign and Fax or Mail this Form

DMHC use only
Call Ref.#

Complete this form if you have completed the complaint process with your health plan and are not satisfied with the resolution or if your health plan did not resolve your complaint within 30 days. However, if your complaint involves an imminent and serious threat to the health of the patient, immediately contact the California HMO Help Center's Consumer Help Line toll free at (888) HMO-2219 or TDD (877) 688-9891.

You may enter your information directly into the fields provided below. Upon completion, print the form and fax or mail it to the address provided at the bottom of the form.

1.
Complainant's Name:
Street Address:
City:
State:  
Zip:       		Telephone Daytime:
Telephone Evening:
 Cell Phone:

E-mail address:
2.
Patient's Name and Address:
(Only if different from Complainant)


3.
Health Plan Name:
Medical Group Name:
Medical Group #:
Patient's ID #
(or Membership #):

4.
Are you a Medi-Cal Beneficiary? Yes  No 
Are you a Medicare Beneficiary? Yes  No 

5.
Have you previously written to your health plan regarding this complaint?
If YES,
Date(s) of contact:

Person(s) contacted:
Phone #:

If NO, you must first complete the complaint process with your health plan (see Consumer Complaint Process section, "How Does the Complaint Process Work?").


6.
Please fully explain the essential facts of this complaint. What health plan service did you not receive? What was wrong with the service received? What billing issues do you have? Explain who, what, where, when, and how.
Please attach photocopies of any correspondence you received from the plan and any other documents that you believe support your complaint. Attach additional paper, if more space is needed.

7.
Have you reported this to any other government agency?
Yes  No 
Agency and file number (if known):

8.
Is there a lawsuit pending? Yes      No  If yes, attach a photocopy of the court documents and provide:
Name of the County
where filed:
Case Number:
Dated Filed:
Name of Representing Attorney:
Telephone Number:
I understand that providing the information is not mandatory, but failure to do so may delay or even prevent further consideration of a resolution to my complaint. I understand that a copy of this complaint may be sent to my health plan.
Date

 Signature: (Once printed sign here)



If you have any questions or need assistance completing this form, call our Consumer Help Line toll free at (888) HMO-2219 or TDD (877) 688-9891.

AUTHORIZATION FOR RELEASE
OF MEDICAL RECORDS

(Person Authorizing Release):
on behalf of (Patient): hereby authorizes (Health Plan):

to release to the Department of Managed Health Care (Department) the medical record(s) in the custody and/or control of the Health Plan, including applicable mental health records, concerning care provided to the patient relating to the Complaint filed with the Department.

This authorization for release of information may be revoked or withdrawn at any time and revocation or withdrawal will apply to all information not previously released to the Department. This authorization will expire one year following the date indicated below and the expiration will apply to all information not previously released to the Department. Your medical records will only be obtained if it is determined to be necessary in order to complete a review of your Complaint. This information will be kept confidential.

THIS MEDICAL AUTHORIZATION IS NOT MANDATORY. HOWEVER, FAILURE TO SIGN THIS RELEASE MAY PREVENT FURTHER ASSISTANCE ON YOUR COMPLAINT.
Date

 Signature: (Once printed sign here)



Please sign the Complaint Form and the Authorization for Release of Medical Records. Attach photocopies of all relevant documents and records as originals cannot be returned.

Fax these documents to:    (916) 229-0465

or Mail to:
    Department of Managed Health Care
    California HMO Help Center
    980 Ninth Street, Suite 500
    Sacramento, CA 95814-2725

NOTICE REQUIRED BY
THE INFORMATION PRACTICES ACT OF 1977
(California Civil Code Section 1798.17)

  1. The California HMO Help Center of the Department of Managed Health Care requests the information solicited by the forms attached to this Notice.


  2. The Chief Administrative Officer, 980 9th Street, Sacramento, CA 95814-2725, telephone number (916) 327-7659, is responsible for the system of records and shall, upon request, inform individuals regarding the location of the Department of Managed Health Care's records and the categories of persons who use the information in the Department of Managed Health Care's records.


  3. The Department of Managed Health Care's records are maintained pursuant to one or more of the following statutes: Health and Safety Code Sections 1344, 1351, 1351.1, 1352, 1353, 1368(b), 1368.02 and 1384.


  4. The submission of all items of information is voluntary.


  5. Failure to provide all or any part of the information requested by the attached form may preclude the California HMO Help Center of the Department of Managed Health Care from reviewing your complaint.


  6. The principal purposes within the Department of Managed Health Care for which the information is to be used is as part of the process to determine:  (1) whether a license, qualification, registration or other authority should be granted, denied, revoked or limited in any way; (2) whether business entities or individuals licensed or regulated by the Department of Managed Health Care are conducting themselves in accordance with the applicable laws; and/or (3) whether laws administered by the Department of Managed Health Care are being or have been violated and whether administrative action, civil action, or referral to appropriate federal, state or local law enforcement or regulatory agencies is appropriate.


  7. Any known or foreseeable disclosures of the information pursuant to subdivision (e) or (f) of Civil Code Section 1798.24 may include transfers to other federal, state, or local law enforcement or regulatory agencies.


  8. Subject to certain exceptions or exemptions, the Information Practices Act grants an individual a right of access to personal information concerning the requesting individual which is maintained by the Department of Managed Health Care. However, Government Code Section 6254 provides that records of complaints to or investigations conducted by the Department of Managed Health Care are exempt from disclosure except as required by law. Additionally, Evidence Code Section 1040 provides a privilege against disclosure of official information where a court determines that the necessity for confidentiality outweighs the public interest in disclosure.