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Network Adequacy
Patient Complaints and Grievances
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Submit Grievance (Complaint) or an Appeal
Submit Grievance (Complaint) or an Appeal
For technical and non-technical issues, please email the Patients' Rights Office at PCG@dmh.lacounty.gov or call (213) 738-4888 / (800) 700-9996 for assistance.
I wish to file a(n)
*
Grievance
Appeal
Check if you are requesting that your appeal be processed through the Expedited Appeals Process
Grievance ID
*
Grievance ID starts with "COM"; exact match required
PERSON FILING
Relationship to Beneficiary/Consumer
Self
Family
Conservator
Provider/Practitioner
PRO Advocate
Are you a Service Provider?
Are you a Service Provider?
No
Are you a Service Provider?
Yes
Service Provider Type
Directly Operated
Legal Entity
Hospital
PRO Advocate Name
*
First Name
*
*
MI
*
Last Name
*
*
Contact Phone Number
*
Email Address
*
*
Address
*
*
City
*
*
State
*
*
Zip Code
*
*
BENEFICIARY/CONSUMER INFORMATION
First Name
*
*
MI
*
Last Name
*
*
Contact Phone Number
*
Email Address
*
*
Address
*
*
City
*
*
State
*
*
Zip Code
*
*
Birth Date
*
*
Medi-Cal #
*
FILED AGAINST
Name of Facility/Provider/Program
*
*
Phone #
*
Address
*
City
*
State
*
Zip Code
*
DESCRIPTION OF GRIEVANCE: (Attach any supporting documents with the Grievance.)
What is the complaint?
*
Did you talk to your provider about the complaint?
Did you talk to your provider about the complaint?
No
Did you talk to your provider about the complaint?
Yes
What was their resolution?
*
What resolution would you like?
*
What did you do to resolve?
*
Current URL
*
Complaint Format
Access Center
Online
Phone
Written
DESCRIPTION OF APPEAL: (Attach any supporting documents with the Appeal.)
Explain why you disagree with the decision on your grievance
*
What resolution would you like?
*
Attach a file
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ACKNOWLEDGEMENT OF YOUR REQUEST
Network Adequacy
Patient Complaints and Grievances