GRIEVANCE FORM En Español or Download & Print En Español In English Grievances must be submitted within 180 calendar days following the incident or action that is the subject of the member’s dissatisfaction. You will receive an Acknowledgement of Receipt of Grievance to your stated method of contact within 5 calendar days of the date the grievance is received by LifeWorks by Morneau Shepell; and receive a Grievance Resolution statement within 5 calendar days of a decision. If you have any questions regarding the grievance process of your specific grievance, please contact EAPQATeam@morneaushepell.com. All grievances will be resolved within 30 calendar days of receipt. If you need assistance to complete this form or have any questions about the grievance process, please call us at 1-800-234-5154. IMPORTANT: We can provide you an interpreter at no cost to you. You can get documents read to you and sent to you in your preferred language. For assistance, please call us at 1-800-234-5154. TTY/TDD: 1-800-999-3004. Member Name* Member’s Date of Birth* Member’s Employer* Daytime Phone # How should we contact you and, if necessary, leave a message (Check all that apply)? PhoneEmailMailDo Not Contact Me Mailing Address Email Address Description of Grievance* Action you would like to have happen* I hereby attest that the information above is true. Enter Initials to confirm* Attention California Members: Please review the following information. 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 1-800-234-5154 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 might 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 a health plan 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-HMO-2219 and a TDD line 1-877-688-9891 for the hearing and speech impaired. The department's Internet Web site www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.