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Member Grievance Form                                                                    CIGNA HealthCare of California, Inc.
                                                                             MAIL TO:   National Appeals Unit
There are two sides to this form.                                                       P.O. Box 5225
Please print clearly.                                                                   Scranton, PA 18505-5225
                                                                                        Member Services: 1.800.244.6224 Toll Free
Complete all sections of this form.                                                                       1.800.321.9545 (TTY)
                                                                             OR FAX:    1.866.254.9406 Toll Free



                     I am submitting a grievance to CIGNA HealthCare of California, Inc. ("CIGNA HealthCare")
              IN AN EMERGENCY, PLEASE CALL 911 OR GO DIRECTLY TO THE NEAREST EMERGENCY ROOM.

      Check this box if this case involves an imminent and serious threat to you or the health of the patient, including
      but not limited to, severe pain, the potential loss of life, limb or major bodily function. If it does, please phone
      CIGNA HealthCare Member Services at 1-800-244-6224 (1-800-321-9545 (TTY) for the hearing and speech
      impaired) or the toll free number on your CIGNA HealthCare Identification Card.

Please read the attached brochure about your right to file grievances with CIGNA HealthCare. To serve you quickly, it is
important that you provide as much information as possible. If you have any questions about the meaning of anything on
this Form, please call Member Services at 1-800-244-6224 or the toll free telephone number on your CIGNA HealthCare
Identification Card.

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 1-800-244-6224 or the toll-free telephone
number on your CIGNA identification card (1-800-321-9545 (TTY) for the hearing and speech impaired) 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 may 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 http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.
                            MEMBER INFORMATION (Member complete this information)
 Name (Last)                                (First)                                     (Middle Initial)    Member Identification Number


 Mailing Address (Street)                                      (City)                                      (State)              (Zip Code)



 Daytime Telephone Number                                                Evening Telephone Number
 (        )                                                              (     )
 Name of Person filing Grievance (if other than member)



                     PATIENT INFORMATION (Complete only if patient is other than member)
 Name (Last)                  (First)                 (Middle Initial)   Relationship to Member             Member Identification Number


 Mailing Address (Street)                                      (City)                                      (State)              (Zip Code)


 Daytime Telephone Number                                                Evening Telephone Number
 (        )                                                              (     )

                                                                                                                     (Continued on Reverse Side)
591327 3-05
                                        MEMBER GRIEVANCE INFORMATION
 List name, phone number and address of the physician or medical group this grievance is about.
 Name of Physician or Medical Group                                                            Telephone Number

                                                                                               (      )
 Address (Street)                                       (City)                             (State)                (Zip Code)



 Briefly outline the specific details of your grievance. Identify what the grievance is, and WHEN the events you describe
 took place. If helpful, please provide COPIES of all itemized bills, checks (both sides) and correspondence related to this
 grievance.
 If this grievance involves a denial for treatment, services or supplies deemed to be experimental for a terminal illness and
 you would like to request a conference as part of the grievance system, please let us know below.




 Attach additional pages to this form, if needed.
 Have you sent any records, correspondence, or other concerns about this case to CIGNA HealthCare Member Services or
 any one else connected with CIGNA HealthCare?              Yes        No
 If yes, please list below when you sent it and to whom. Please include their phone or facsimile number if you know it.
 CIGNA HealthCare Contact                                                                      Telephone or Facsimile Number

                                                                                               (      )
 Date(s)



                                                    CERTIFICATION
 I certify that this information is true and correct.
 Member/Patient Signature                                                                      Date




WHEN COMPLETED, MAIL THIS FORM TO:                      CIGNA HealthCare of California, Inc.
                                                        National Appeals Unit
                                                        P.O. Box 5225
                                                        Scranton, PA 18505-5225
                                  OR, FAX IT TO:        866-254-9406 Toll Free


 FOR INTERNAL USE ONLY:
    Initial Determination             Complaint          Appeal