GRIEVANCE/APPEAL & DISPUTE RESOLUTION FORM
COMPLAINT NUMBER:
INSTRUCTIONS:
Fill out this form as completely as possible, including as much detail about your concern and how you feel it could be resolved.
If you wish, Customer Services can assist you in completing the form. Customer Services is located at 1200 N. West Avenue,
Jackson, MI 49202 or call 517-780-3332 or 1-866-630-3690 and in Hillsdale by appointment.
APPEAL TYPE: EXPEDITED GRIEVANCE TYPE:
FAMILY SUPPORT SUBSIDY DENIAL QUALITY OF TREATMENT
SECOND OPINION OF INITIAL ACCESS DENIAL QUALITY OF SERVICE
SECOND OPINION OF HOSPITALIZATION DENIAL AUTHORIZATION/HOSPITAL RECONSIDERATION
NEGATIVE SERVICE DECISION CLAIMS DISPUTE
CONTRACT/CREDENTIALING DISPUTE
REQUESTING CHANGE IN PSYCHIATRIST
Did complainant try to resolve before filing grievance/appeal (i.e. speak to doctor, therapist, Team Supervisor, etc.)
Yes No N/A
COMPLAINANT’S NAME: COMPLAINANT’S PHONE NUMBER:
COMPLAINANT’S ADDRESS: NAME OF CONSUMER INVOLVED (if applicable):
EXPLAIN/DESCRIBE THE GRIEVANCE/APPEAL/REQUEST (You may attach additional pages if necessary):
HOW DO YOU FEEL THIS COULD BE RESOLVED?
DATE
SIGNATURE OF PERSON COMPLETING FORM
REVISED 8/2015
LW/#6-02.01-A (720)
