Members / New York Access to Care Complaint Form New York Access to Care Complaint Form 1 Enter Information 2 Review Details 3 Submit If you would like to submit your access to care grievance online, please complete the online form below and click Next to review before final submission. / Si desea presentar su queja acceso a la atención en línea, complete el siguiente formulario en línea y haga clic en Next (Siguiente) para revisarlo antes de la enviarlo definitivamente. Should you have any questions about this process, please contact us at . / Si tiene alguna pregunta sobre el proceso, comuníquese con nosotros al . Section 1: Member Information SECCIÓN 1: INFORMACIÓN DEL AFILIADO Member Name / Nombre del afiliado Please enter a Member Name. Member Birthdate / Fecha de nacimiento del afiliado Format: MM/DD/YYYY Please enter a Member Birthdate. Plan and Member ID # / Plan de salud y N.° de identificación del afiliado Please enter a Plan and Member ID #. Member Phone Number / N.° de teléfono del afiliado Please enter a Member Phone Number. Format: xxx-xxx-xxxx Address / Dirección Please enter a Member Address. Address 2 / Dirección 2 City / Ciudad Please enter a City. State / Estado Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Please enter a State. Zip / Código Postal Please enter a Zip. Section 2: Requester Information SECCIÓN 2: INFORMACIÓN DEL SOLICITANTE If you are not the member, please provide the following information/Si usted no es el afiliado, brinde la siguiente información: Your Name / Su nombre Please enter Your Name. Relationship to Member / Relación con el afiliado Please enter a Relationship to Member. Your Phone Number / Su núm. de teléfono Format: xxx-xxx-xxxx Please enter a Your Phone Number. Your Address / Su dirección Please enter Your Address. Address 2 / Dirección 2 City / Ciudad Please enter Your City. State / Estado Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Please enter Your State. Zip / Código Postal Please enter Your Zip. Are you the member’s authorized representative or legal guardian? / ¿Es usted el representante autorizado o tutor legal del afiliado? Yes / Sí No You must answer this question. (Note: We must have written authorization to allow you to act on the member’s behalf.) / (Nota: Debemos tener una autorización por escrito para permitirle tomar decisiones en nombre del afiliado). Section 3: Grievance Information SECCIÓN 3: INFORMACIÓN SOBRE LA QUEJA Please explain your grievance. Include details, such as / Explique su queja. Incluya detalles como los siguientes: The name of the provider who will or has provided care/El nombre del proveedor que brindó o brindará atención The date that the event took place/La fecha en la que tuvo lugar el evento The specific reason why you don’t agree with the decision/El motivo específico por el que no está de acuerdo con la decisión Details / Detalles Please enter Details. Action you would like to have happen / Medida que le gustaría que se implemente Please enter an Action you would like to have happen. PLEASE REVIEW YOUR INFORMATION BEFORE SUBMISSION. Use Previous button at the bottom of the form to go back and make revisions. Otherwise click Submit to finalize your submission. Section 1: Member Information SECCIÓN 1: INFORMACIÓN DEL AFILIADO Member Name / Nombre del afiliado Please enter a Member Name. Member Birthdate / Fecha de nacimiento del afiliado Format: MM/DD/YYYY Please enter a Member Birthdate. Plan and Member ID # / Plan de salud y N.° de identificación del afiliado Please enter a Member ID #. Member Phone Number / N.° de teléfono del afiliado Format: xxx-xxx-xxxx Please enter a Member Phone Number. Address / Dirección Please enter a Member Address. Address 2 / Dirección 2 City Please enter a City. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Please enter a State. Zip Please enter a Zip. Section 2: Requester Information SECCIÓN 2: INFORMACIÓN DEL SOLICITANTE If you are not the member, please provide the following information/Si usted no es el afiliado, brinde la siguiente información: Your Name / Su nombre Please enter Your Name. Relationship to Member / Relación con el afiliado Please enter a Relationship to Member. Your Phone Number / Su núm. de teléfono Format: xxx-xxx-xxxx Please enter a Your Phone Number. Your Address / Su dirección Please enter Your Address. Address 2 / Dirección 2 City Please enter Your City. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Please enter Your State. Zip Please enter Your Zip. Are you the member’s authorized representative or legal guardian? / ¿Es usted el representante autorizado o tutor legal del afiliado? Yes No You must answer this question. Section 3: Grievance Information SECCIÓN 3: INFORMACIÓN SOBRE LA QUEJA (Note: We must have written authorization to allow you to act on the member’s behalf.) / (Nota: Debemos tener una autorización por escrito para permitirle tomar decisiones en nombre del afiliado). Please explain your grievance. Include details, such as / Explique su queja. Incluya detalles como los siguientes: The name of the provider who will or has provided care/El nombre del proveedor que brindó o brindará atención The date that the event took place/La fecha en la que tuvo lugar el evento The specific reason why you don’t agree with the decision/El motivo específico por el que no está de acuerdo con la decisión Details / Detalles Please enter Details. Action you would like to have happen / Medida que le gustaría que se implemente Please enter an Action you would like to have happen. Please complete the reCAPTCHA challenge field above. Your form was successfully completed.Your grievance will be investigated by the appropriate team. If you have questions, please call the phone number on your Member ID card.Submit another entry Your submission failed.Please check your entry and try again. If you continue to receive this error, please contact support.
