Member Grievance Form …

                                Member Grievance Form
                            Please complete, and mail or fax to:
                          CIGNA Dental Health of California, Inc.
                                     P.O. Box 188044
                                 Chattanooga, TN 37422
                                    Fax: 559.735.8257


[ ] 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 call CIGNA Dental Member
Services at 1.800.244.6224 in addition to submitting this form. The hearing impaired
may call the State TTY toll-free relay service listed in their local telephone directory.
Subscriber/Patient Information

Member Name:

Last ____________________ First __________________ Middle Initial __

Member ID Number __________________________________________

Member Employer ___________________________________________

Member Mailing Address:

Street_______________________________

City ________________________________

State _______________________________

ZIP _________________________________

Daytime Telephone Number (____ ) _____________________________

Evening Telephone Number (____) _______________________________

Email Address ________________________________________________

Patient Information (if different than Member)

Patient Name:

Last ____________________First_________________ Middle Initial

DENTAL OFFICE INFORMATION

Dental Office Number ____________________________

Dental Office Name_______________________________

Dentist Name:

Last ___________________________

First ___________________________


Revised 11/15/2007
Dentist Address:

Street _______________________________

City_________________________________

State _______________________________

ZIP _________________________________

Dental Office Phone Number ( ____ )

Date(s) of Service

Grievance Information

Nature of Problem:

____ Dentist's Services ____ Benefits ____Charges

____ Appointment ____ Attitude of Dentist ____Attitude of Dental Office Staff

____ Other

Description of Problem:
_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

May we send a copy of this form to the dentist you named above? Yes_______ No ____

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 call your health
plan at 1.800.244.6224. Please use your health plan's grievance process before contacting
the Department. Using 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,
or a grievance that has not been satisfactorily resolved by your health plan, or a grievance that
has not been resolved after 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 Web site,
http://www.hmohelp.ca.gov, has complaint forms, IMR application forms and instructions
online.




Revised 11/15/2007