Grievance and Appeal Form

Please fill out the form below and click “Submit,” then review it to make sure it is correct. When everything is correct, click “Submit” again, and the form will be sent to us. If you have any problems filling out this form, please call our Customer Service department at the numbers below.

* = Mandatory Fields

Date of Complaint:

Friday, April 19, 2024

* Name of person filling out this form:

*Date of Incident/Denial:

* Relationship:

* Member First Name:

MI:

* Member Last Name:

* Contact/Message Number:

* Current Home Address:

* City:

* Zip Code:

* Member ID Number:

* Member's Date of Birth:

* Do you have a denial letter signed by a doctor?

Yes

Description of the concern or issue (include names, date, and details):

How have you tried to resolve this problem?

Please take some time to review this form to make any changes or add more information. If you have any problems filling out this form, please call our Customer Service Department at 1-888-587-8088.

Thank you for taking time to share your concerns with CalOptima. Please read your CalOptima Member Handbook for more information on your member rights, health coverage and available services.

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