HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers

If you are not satisfied with services you have received from your health plan, medical group, or provider (including office staff), you should talk to your provider, your medical group, or your health plan's customer service department. If you still are not satisfied, you might want to complain in writing. You can use this letter to make a complaint about the quality of care or service you received. Be sure to add your own facts to this letter.

 Here are some tips for using this letter:

• All of the language suggested may not apply to you. Use only the parts of the letter that are appropriate based on your facts.
• Places where you can insert your information are identified by brackets ("[ ]"), and the description of the information to add is underlined. You should delete the brackets and the sample description, and fill in your own information, where it applies.
• The letter includes advice to you that is in parenthesis ("{ }"), with the text of the advice in italics. You should delete these sections from your letter.
• The sample letter is addressed to the "Customer Service Department." Your health plan may use a different name for the department that receives complaints, grievances and appeals from its members. Check your health plan documents or member handbook [usually called the Evidence of Coverage (EOC) or Summary Plan Description (SPD)], or call your medical group or health plan, to find out to whom your letter should be sent.
• Check your health plan documents or member handbook (EOC or SPD) for your plan's requirements for filing a complaint, grievance or appeal. You should follow your health plan's procedures, including any time limits, when you file a complaint, grievance or appeal.
• There are different laws that apply to different types of health care coverage. The laws that apply in your circumstances may depend on where you live, what type of health plan you have, and how you get your coverage. Check your EOC for information about the agency that regulates your health plan, then check with the agency to see what set of laws apply to your case. Remember, it is not necessary to quote the law in your letter, but doing so may help make your case stronger.

For example, the legal standards that relate to quality of care for Californians in Health Maintenance Organizations (HMOs) are found in California Health & Safety Code '' 1367 and 1373.96. These sections of the law apply only to licensed California health plans regulated by the California Department of Corporations.

• Attachments - You should attach to your letter copies of any information that helps explain why you are dissatisfied with the care you received. In some cases, a letter may have no attachments; in other cases, there may be many.
• Sending Copies - You should consider sending copies of your letter to others who may be helpful in resolving your problem. Suggestions for who you might want to send copies to are listed at the end of the letter. You should decide who might be helpful in resolving, and who you would like to know about, your problem. It is not likely to be appropriate for you to send copies of your letter to all who are listed on the sample letter under the "cc."

Health Rights Hotline
Sample Letter for Quality of Care Complaint
(see tips for using this letter)

[Date]

[Your Medical Group or Health Plan]
Customer Service Department
[address]

Dear Customer Service Department:

I am writing to express my dissatisfaction with services I received from [name of provider] on [date].

I am unhappy with the services provided by [name of provider] for the following reasons: {Describe the problem you experienced, how it impacted your health, and why you feel the problem should not have occurred or what should have been done differently; include any relevant date(s) and any names of people involved, and any actions you have already undertaken attempting to resolve the problem.}

I would appreciate it if you would investigate this matter and take appropriate action to prevent the problem from happening again. You may contact me at [telephone number] if you would like any additional information. Please notify me in writing of the results of your investigation.

Sincerely,

[Your name]

cc: {Possible individuals and/or groups to whom you can consider sending copies of your letter:}

[Health Plan Medical Director]
[Medical Group Medical Director]
[State disciplinary or licensing board]
[Your doctor]
[Party you are complaining about]
[Your employer or insurance broker]
[State regulatory agency]

Attachment(s): {list and attach any written documentation that supports your complaint}