OneCare Connect

Online Member Request, Appeal Or Complaint Form

Please fill out the form below to request a coverage decision, appeal or to file a formal complaint for any part of care or service you had from OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan). Click “Submit” to make sure your information is right before you submit your form. If you have any problems filling out this form, please call OneCare Connect Customer Service department at 1-855-705-8823. TDD/TTY users can call 1-800-735-2929.

If you wish to have someone represent you other than your doctor, you must submit an Appointment of Representative Form or a legal document authorizing a representative to act on your behalf.

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Date of Complaint:

Wednesday, December 11, 2019

 
 
 
 
 
 
 
 
 
 
 
 
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 OneCare Connect Customer Service department at 1-855-705-8823. TDD/TTY users can call 1-800-735-2929.

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

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To file a complaint with Medicare, click on the following link to complete a complaint form on the Medicare website: Medicare Complaint Form.

H8016_20WEB001_2020_A Accepted 9/29/19

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