PHPC Grievance Form

1 Enter Information
2 Review Details
3 Submit

If you would like to submit your grievance online, please complete the online form below and click Next to review before final submission. If you would prefer to complete a hard copy form, please print out the Grievance Form on the Members page. / Si desea presentar su queja en línea, complete el siguiente formulario en línea y haga clic en Next (Siguiente) para revisarlo antes de la enviarlo definitivamente. Si prefiere completar un formulario impreso, imprima el Formulario de quejas desde la página de afiliados.

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

Please enter a Member Name.
Format: MM/DD/YYYY
Please enter a Member Birthdate.
Please enter a Member ID #.
Please enter a Member Phone Number.
Format: xxx-xxx-xxxx
Please enter a Member Address.
Please enter a City.
Please enter a State.
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:

Please enter Your Name.
Please enter a Relationship to Member.
Format: xxx-xxx-xxxx
Please enter a Your Phone Number.
Please enter Your Address.
Please enter Your City.
Please enter Your State.
Please enter Your Zip.
Are you the member’s authorized representative or legal guardian? / ¿Es usted el representante autorizado o tutor legal del afiliado?
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 claim or reference number for the specific decision that you disagree with/El número de reclamación o referencia de la decisión específica con la que no está de acuerdo
  • The specific reason why you don’t agree with the decision/El motivo específico por el que no está de acuerdo con la decisión
Please enter Details.
Please enter an Action you would like to have happen.
Is this grievance about an imminent and serious threat to the health of the patient, including, but not limited to, severe pain, potential loss of life, limb, or major bodily function? For immediate attention, please call .
You must answer this question.
Should you have any questions about the process, please contact us at 1-800-228-1286. / Si tiene alguna pregunta sobre el proceso, comuníquese con nosotros al 1-800-228-1286.

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

Please enter a Member Name.
Format: MM/DD/YYYY
Please enter a Member Birthdate.
Please enter a Member ID #.
Format: xxx-xxx-xxxx
Please enter a Member Phone Number.
Please enter a Member Address.
Please enter a City.
Please enter a State.
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:

Please enter Your Name.
Please enter a Relationship to Member.
Format: xxx-xxx-xxxx
Please enter a Your Phone Number.
Please enter Your Address.
Please enter Your City.
Please enter Your State.
Please enter Your Zip.
Are you the member’s authorized representative or legal guardian? / ¿Es usted el representante autorizado o tutor legal del afiliado?
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 claim or reference number for the specific decision that you disagree with/El número de reclamación o referencia de la decisión específica con la que no está de acuerdo
  • The specific reason why you don’t agree with the decision/El motivo específico por el que no está de acuerdo con la decisión
Please enter Details.
Please enter an Action you would like to have happen.
Is this grievance about an imminent and serious threat to the health of the patient, including, but not limited to, severe pain, potential loss of life, limb, or major bodily function? For immediate attention, please call .
You must answer this question.
Please complete the reCAPTCHA challenge field above.