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Member Area

Patient Grievance Form

Golden West Dental & Vision
P.O. Box 659471
San Antonio, TX 78265

Our Member Services department is available Monday through Friday 8 am to 5 pm PST and can be reached at the number listed on your member identification card.

Fax: (805) 713-2435

If help is needed to complete this form or if you prefer to file a grievance by telephone, please contact Golden West Member Services at the number listed on the back of your member identification card.

Subscriber Name Member # Plan
Patient Employer/Group
Address
City Zip Code Phone #
Email Address

Name of Dental/Vision Office
Office Address City

Grievance Details (Please provide as many details as possible)
Your Preferred Solution

If help is needed to complete this form, your network provider is available to assist you.

Our Member Services department is available Monday through Friday 8 am to 5 pm PST and can be reached at the number listed on your member identification card. If help is needed to complete this form or if you prefer to file a grievance by telephone, please contact Golden West Member Services at the number listed on the back of your member identification card.

Comuníquese con el servicio al cliente de Golden West si necesita este formulario traducido al español.

GRIEVANCE FORM ENGLISH - Instructions

GRIEVANCE FORM SPANISH -- ESPAÑOL FORMULARIO DE QUEJA

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 (866) 926-8078 and use your health plan's grievance process before contacting the department. 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 California Department of Managed Health Care 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 California Department of Managed Health Care Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.