Fill - Free fillable OmbudsContactForm Questions? UsethisformtocontacttheOmbudsOfficeifyourproblemorissuehasnotbeenresolvedby:calling theServiceCenter,filingaCoveredCaliforniacomplaint,orfilinganappeal.Ifyouhavetriedoneof PDF form

OmbudsContactForm  

 (OVER) 1



Instructions:

UsethisformtocontacttheOmbudsOfficeifyourproblemorissuehasnotbeenresolvedby:calling

theServiceCenter,filingaCoveredCaliforniacomplaint,orfilinganappeal.Ifyouhavetriedoneofthe

methodslistedandstillhavebeenunabletoresolveyourproblem,TheOmbuds

Officecanresearch

yourcaseandhelpyoufindaresolution.Ifwecannothelpyou,wewillexplainwhywecouldnotor

referyoutoaresourcethatmaybeableto.



Questions?

Ifyouneedhelpinanotherlanguageorwouldliketocontactusoverthephone,calltheOmbudsOffice

at(888)726‐0840,CoveredCATTYat(888)889‐4500orE‐mailusatOmbuds@covered.ca.gov.

Informationaboutyou?

FirstName: LastName:

PrimaryContactNumber: SecondaryContactNumber:

E‐mail:

MailingAddress:

City: State: Zip:

CaseID(optional): DateofBirth(optional):



Howcanwecontactyou?

☐E‐mail ☐Phone ☐Mail



Ifbyphone,whenisthebesttimetocontactyou?

(Multipleoptionscanbeselected)

☐Morning:8am‐noon ☐Mid‐Day:11am‐2pm

☐Afternoon:12pm‐5pm



Whatareyoucontactingusabout?

☐AccesstoCare ☐Enrollment

☐AccountIssue ☐GeneralQuestion

☐AppealsIssue ☐Termination

☐AQualifiedHealthPlan ☐Other



Continuedonnextpage

2



Tellusaboutyoursituation(Optional‐Usemorepaperifyouneedmorespacetowrite)



ConsenttoreferthisformtoanotherDepartment/Organization:

TheOmbudsOfficemayhavetoreferthisformtoanotherstateagencyorconsumerassistance

group.Doyouagreetohaveyourinformationsenttoanotherstateagency/consumergroup?

☐ Yes ☐ No



Returnthisformby:

E‐mailthisformto:



Ombuds@covered.ca.gov



Mailthisformto:

CoveredCalifornia

OmbudsOffice

1601ExpositionBlvd

Sacramento,CA95815

Faxthisformto:



(888)726‐0841



WhatHappensNext?

TheOmbudsOfficewillreviewyourformandrespondtoyouin1‐3business days.Pleaseallowupto

5businessdaysformail.



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OmbudsContactForm Questions UsethisformtocontacttheOmbudsOfficeifyourproblemorissuehasnotbeenresolvedby:calling theServiceCenter,filingaCoveredCaliforniacomplaint,orfilinganappeal.Ifyouhavetriedoneofthe methodslistedandstillhavebeenunabletoresolveyourprob

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Fillable OmbudsContactForm Questions? UsethisformtocontacttheOmbudsOfficeifyourproblemorissuehasnotbeenresolvedby:calling theServiceCenter,filingaCoveredCaliforniacomplaint,orfilinganappeal.Ifyouhavetriedoneof

Fill Online, Printable, Fillable, Blank OmbudsContactForm Questions? UsethisformtocontacttheOmbudsOfficeifyourproblemorissuehasnotbeenresolvedby:calling theServiceCenter,filingaCoveredCaliforniacomplaint,orfilinganappeal.Ifyouhavetriedoneof Form

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