Online Grievance

Please complete this online form with information about your grievance. We will acknowlege receipt of your grievance within five working days. All grievances will be resolved within 30 days whenever possible. If your grievance is urgent or an emergency please call the Plan toll-free at (877) 433-6825 for an immediate review. Members who file a grievance against the Plan will not be discriminated or retaliated against in any way.

Member Information

Member Name
Member Identifcation Number
Subscriber Name (if different from above)
Subscriber Number
Daytime Phone

Facility Information

Facility Name
Facility Address
Treating Providers Name(s)
List then name(s) of the facility personnel you spoke with about this matter

Grievance Information

This grievance is being files agains:

The Plan Facility Personnel
The Facility The Treating Provider

Date(s) grievance Occured

Describe the incident and your grievance

I Authorize any dentist, doctor, hospital or other medical facility or professional to release any and all medical/dental records that relate to my grievance or that may affect the Plan's review and resolution

I give permission to California Dental Network, Inc. to discuss this grievance with the person(s) named below, including any pertinent medical/dental records and/or personal health information needed to assist in the processing of this Grievance

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 1-714-479-0777 or toll-free 1-877-4-DENTAL and use your Health Plan's grievance process before contacting the Department. For the hearing and speech impaired, dial 711 to call with the Telecommunications Relay Service. 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 has complaint forms, IMR application forms and instructions online.