Scribd Logo
Upload

Welcome to Scribd!

  • 190 views

    Grievance: Sample Grievance Letter Sample Grievance Letter Sample Grievance Letter

    Uploaded by

    mahender yadav
    This document provides a sample grievance letter template that can be used to file a grievance with a health maintenance organization (HMO). The template includes sections for including identifying information like the member ID number and contact details. It specifies filing the letter as either a standard grievance or emergency grievance and expects a response within 30 days or 48 hours respectively. The letter prompts the user to describe the problem, including relevant details like appointment dates and names, and how they want the issue resolved. It reminds to send copies to any assisting parties.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Grievance: Sample Grievance Letter Sample Grievance Letter Sample Grievance Letter

    Uploaded by

    mahender yadav
    190 views1 page
    This document provides a sample grievance letter template that can be used to file a grievance with a health maintenance organization (HMO). The template includes sections for including identifying information like the member ID number and contact details. It specifies filing the letter as either a standard grievance or emergency grievance and expects a response within 30 days or 48 hours respectively. The letter prompts the user to describe the problem, including relevant details like appointment dates and names, and how they want the issue resolved. It reminds to send copies to any assisting parties.

    Original Description:

    Sample grievance

    Original Title

    Grievance2-133

    Copyright

    © © All Rights Reserved

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides a sample grievance letter template that can be used to file a grievance with a health maintenance organization (HMO). The template includes sections for including identifying information like the member ID number and contact details. It specifies filing the letter as either a standard grievance or emergency grievance and expects a response within 30 days or 48 hours respectively. The letter prompts the user to describe the problem, including relevant details like appointment dates and names, and how they want the issue resolved. It reminds to send copies to any assisting parties.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    190 views1 page

    Grievance: Sample Grievance Letter Sample Grievance Letter Sample Grievance Letter

    Uploaded by

    mahender yadav
    This document provides a sample grievance letter template that can be used to file a grievance with a health maintenance organization (HMO). The template includes sections for including identifying information like the member ID number and contact details. It specifies filing the letter as either a standard grievance or emergency grievance and expects a response within 30 days or 48 hours respectively. The letter prompts the user to describe the problem, including relevant details like appointment dates and names, and how they want the issue resolved. It reminds to send copies to any assisting parties.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    Sample Grievance Letter

    Sample Grievance Letter


    Sample Grievance Letter
    The words that are slanted are directions.

    GRIEVANCE
    Your Member ID Number
    Your Name
    Your Address
    Your Town, State and Zip Code
    Name of HMO
    Address of HMO
    Town, State and Zip Code of HMO
    Dear Grievance Specialist,

    Todays Date

    I am writing to file a grievance with Name of HMO. I am having a problem


    with PCP, medical treatment, home health care or other problem. I am submitting
    this letter as a (pick one) GRIEVANCE/ EMERGENCY GRIEVANCE because I do not
    agree with the decision about my care, I do not like the way I was treated,(or any
    other problems).
    My HMO ID number is __________________________. My ACCESS card number is
    ________________________. My Primary Care Provider (PCP) is
    ___________________________.
    Begin your description here. Write about the steps that led up to the
    problem. In include facts like appointment dates, times and providers names and
    people who you spoke with. Tell them how you want the problem fixed. Be clear
    about everything that happened.
    I expect a response to my grievance within 30 days in writing (48 hours if it
    is an emergency grievance). Please send all information to me at the above
    address. Also send a copy to the name and address of an agency or person that
    is helping you like your PCP or an advocate.
    Sincerely,

    Sign your name


    Print your name
    Cc: Name of anyone else you are sending the letter to
    Sample Grievance Letter
    Sample Grievance Letter

    Sample Grievance Letter

    You might also like