Members Banner

File a Grievance or Appeal

 

Please click on your state to access the Grievance & Appeals Forms.

 

California


California Grievance Form - Submit Online Link Icon
California Grievance Form PDF Icon
CA Request for Review of Cancellation, Rescission, or Nonrenewal PDF Icon  
GMC NAR Your Rights (Knox-Keene) PDF Icon
PHP NAR Your Rights (Knox-Keene) PDF Icon
State Fair Hearing Form PDF Icon
IMR Form PDF Icon  
CMS - MEDICAID SECTION 1135 WAIVER COVID-19 PDF Icon
 
Español
Formulario de quejas de California - Enviar en línea Link Icon
Formulario de queja de California PDF Icon
Solicitud de CA de revisión de cancelación, rescisión o no renovación PDF Icon
GMC NAR Sus derechos (Knox-Keene) PDF Icon
PHP NAR Sus derechos (Knox-Keene) PDF Icon
Formulario de audiencia imparcial estatal PDF Icon
Formulario de solicitud / queja de revisión médica independiente (IMR) PDF Icon
CMS - MEDICAID SECCIÓN 1135 RENUNCIA COVID-19 PDF Icon
 
IMR Form Other Languages Available 
ArabicPDF Icon   Armenian PDF Icon   Chinese PDF Icon  
Farsi PDF Icon   Japanese PDF Icon   Khmer PDF Icon  
Korean PDF Icon   Lao PDF Icon   Hindi PDF Icon  
Hmong PDF Icon   Punjabi PDF Icon   Russian PDF Icon  
Tagalog PDF Icon   Vietnamese PDF Icon
 
GA Form Other Languages Available 
ArabicPDF Icon   Armenian PDF Icon   Chinese PDF Icon  
Farsi PDF Icon   Khmer PDF Icon   Hmong PDF Icon  
Korean PDF Icon   Russian PDF Icon   Tagalog PDF Icon  
Vietnamese PDF Icon
 

Nevada

 

Missouri

 

Florida

 

All Other States

Members Banner

Members

File a Grievance or Appeal

 

Please click on your state to access the Grievance & Appeals Forms.

 

California


California Grievance Form - Submit Online Link Icon
California Grievance Form PDF Icon
CA Request for Review of Cancellation, Rescission, or Nonrenewal PDF Icon  
GMC NAR Your Rights (Knox-Keene) PDF Icon
PHP NAR Your Rights (Knox-Keene) PDF Icon
State Fair Hearing Form PDF Icon
IMR Form PDF Icon  
CMS - MEDICAID SECTION 1135 WAIVER COVID-19 PDF Icon
 
Español
Formulario de quejas de California - Enviar en línea Link Icon
Formulario de queja de California PDF Icon
Solicitud de CA de revisión de cancelación, rescisión o no renovación PDF Icon
GMC NAR Sus derechos (Knox-Keene) PDF Icon
PHP NAR Sus derechos (Knox-Keene) PDF Icon
Formulario de audiencia imparcial estatal PDF Icon
Formulario de solicitud / queja de revisión médica independiente (IMR) PDF Icon
CMS - MEDICAID SECCIÓN 1135 RENUNCIA COVID-19 PDF Icon
 
IMR Form Other Languages Available 
ArabicPDF Icon   Armenian PDF Icon   Chinese PDF Icon  
Farsi PDF Icon   Japanese PDF Icon   Khmer PDF Icon  
Korean PDF Icon   Lao PDF Icon   Hindi PDF Icon  
Hmong PDF Icon   Punjabi PDF Icon   Russian PDF Icon  
Tagalog PDF Icon   Vietnamese PDF Icon
 
GA Form Other Languages Available 
ArabicPDF Icon   Armenian PDF Icon   Chinese PDF Icon  
Farsi PDF Icon   Khmer PDF Icon   Hmong PDF Icon  
Korean PDF Icon   Russian PDF Icon   Tagalog PDF Icon  
Vietnamese PDF Icon
 

Nevada

 

Missouri

 

Florida

 

All Other States