Download GRIEVANCE AND APPEAL FORM

GRIEVANCE AND APPEAL FORM
PLEASE COMPLETE ALL OF THE SECTIONS BELOW, AND SIGN
Member Name
Member ID Number
Date
Date of Birth
Home Address
Telephone Number
Member ID #: __________________ Date of Birth: ______________
Name of Person Filing Grievance/Appeal (if not member)
Date of Occurrence
Date(s) of Occurrence/Service
IMPORTANT: In your own words, please describe your concern or issue in detail and any facts you
feel should be considered in the review of your grievance/appeal: (Use additional sheet(s) if
necessary) Gather copies of any documents that can help us understand the grievance/appeal.
Please send completed form and supporting documentation to the address/fax listed below.
Member Signature
Date
Authorized Representative Signature
Date
Simply Healthcare Plans, Inc.
9250 W. Flagler Street, Suite 600
Miami, FL. 33174-3460
If you need assistance, please call our Member Services department at 877-577-0115 (TTY 711).
From October 1 to February 14, we are open 7 days a week from 8 a.m. - 8 p.m., EST. Beginning
February 15 until September 30; we are open Monday through Friday, 8 a.m. - 8 p.m.
We do not discriminate, exclude people, or treat them differently on the basis of race, color, national
origin, sex, age or disability in our health programs and activities.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-877-577-0115 (TTY: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang
ki disponib gratis pou ou. Rele 1-877-577-0115 (TTY: 711).
Y0114_17_29302_I_09282016