Member Grievance Form

This form is optional. You may also file a complaint by calling Health Plan of San Mateo Grievance and Appeals Unit.

If you have questions about this form or would like to file a complaint verbally, please call us at 1-888-576-7227 or 650-616-2850. TTY users may call 1-800-735-2929 or dial 7-1-1. Our office hours are Monday through Friday, 8:00 AM to 5:00 PM.

We want to help you resolve your complaint to your satisfaction as quickly as possible. We will not discriminate against you or limit your benefits because you express concerns or file a complaint. Your provider (doctor) also cannot discriminate against you because you file a complaint.

Member's Name*

ID Number

Date of Birth*

Address

City

State

Zip

Telephone Number*

Complaint Filed By*

Member / Self
Parent/Guardian (if Member is under 18 years old)
Provider
Authorized Representative

*If this complaint is being filed by the Member’s Authorized Representative, an Appointment of Representative (AOR) Form or other written proof of legal representation is required. To obtain an AOR Form, please call Grievance and Appeals at 1-888-576-7227 or 650-616-2850. You can also find the AOR form online at www.hpsm.org.

Other (Please state your relationship to the Member)

Please describe the problem in detail*

When did this incident happen?

Where did it happen?

What would you like to see happen?

(If your complaint is against your doctor or other provider, please complete the section below:

Name of Provider/Doctor

Provider’s Address (if available)

City

State

Zip

Provider’s Phone Number (if available)

Do you have a problem that needs medical attention in the next three days, or are you in severe pain? (If you need immediate medical attention, please go to the nearest emergency room.)*

Yes No

If yes, please explain

After receiving this completed form, an HPSM’s Grievance and Appeals Coordinator will call you to discuss your complaint and to review HPSM’s grievance (complaint) process.

The Department of Managed Health Care requires Health Plan of San Mateo to inform you of the following:

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 1-800-750-4776 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 HPSM 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’s internet website http://www.dmhc.ca.gov has complaint forms, IMR application forms, and instructions online.

Confidential Member Complaint (Grievance) Form