Golden West Dental  
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 1-(866)-926-8078

If you would prefer to fax your grievance to us, please fax it with supporting documentation to (855) 273-2689. For your convenience, grievance forms are available at the bottom of this screen.

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 1-(866)-926-8078

 
  Subscriber Name
    Member #
    Plan (Optional)
    Patient
    Employer/Group (Optional)
    Address (Optional)
    City (Optional)
    Zip Code (Optional)
    Phone #
    Email
     
    Name of Dental/Vision Office (Optional)
    Office Address (Optional)
    City (Optional)
 
 
       
 
Grievance Details (Please provide as many details as possible)
   
 
Your Preferred Solution
   
 

 

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

Our Member Services department is available Monday through Friday 8 am to 5 pm PST and can be reached at 1-(866)-926-8078. 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 1-(866)-926-8078.

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

GRIEVANCE FORM - ENGLISH

GRIEVANCE FORM - SPANISH - ESPAÑOL FORMULARIO DE QUEJA

GRIEVANCE FORM INSTRUCTIONS - ENGLISH

GRIEVANCE FORM INSTRUCTIONS - SPANISH - ESPAÑOL INSTRUCCIONES DEL FORMULARIO DE QUEJA

MEMBER CANCELLATION OF COVERAGE GRIEVANCE FORM - ENGLISH

MEMBER CANCELLATION OF COVERAGE GRIEVANCE FORM - SPANISH - ESPAÑOL FORMULARIO DE QUEJA POR CANCELACIÓN

GROUP CANCELLATION OF COVERAGE GRIEVANCE FORM - ENGLISH

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-(866)-926-8078 or at the TDD/TTY line 711 for the hearing and speech impaired 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 department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department internet website https://www.dmhc.ca.gov/ has complaint forms, IMR application forms and instructions online.