STAGE DEV MAY, 2013

Use Secure on-line GRIEVANCE FORM

CCHP Individual and Family Plan

You have the right to file a grievance about any of your medical care or service. If you want to file a grievance, please use this form. There is a process you need to follow to file a grievance. Chinese Community Health Plan must, by law, give you an answer within 30 days. If you have any questions, please feel free to call your doctor's office or CCHP Member Services at 1-415-834-2118 or 1-888-775-7888 toll free. If you think that waiting for an answer from CCHP will hurt your health, call Member Services and ask for an "Expedited Review."

Please provide the following information (ALL fields marked with an asterisk (*) are mandatory):

(Last, first, middle initial)
(xxx-xxx-xxxx)
Name of person filing if different from above/relationship
(mm/dd/yyyy)
Describe the problem in detail
(First and Last Name)
(mm/dd/yyyy)
(mm/dd/yyyy)
STAGE DEV MAY, 2013