Member Grievance FormMember Grievance Form
GRIEVANCE FORM, NON-MEDICARE
Nondiscrimination Notice Kaiser Permanente does not discriminate on the basis of age, race, ethnicity, color, national origin, cultural background, ancestry, religion, sex, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, source of payment, genetic information, citizenship, primary language, or immigration status. Language assistance services are available from our Member Service Contact Center 24 hours a day, 7 days a week (except closed holidays). Interpreter services, including sign language, are available at no cost to you during all hours of operation. Auxiliary aids and services for individuals with disabilities are available at no cost to you during all hours of operation. We can also provide you, your family, and friends with any special assistance needed to access our facilities and services. You may request materials translated in your language at no cost to you. You may also request these materials in large text or in other formats to accommodate your needs at no cost to you. For more information, call 1-800-464-4000 (TTY 711). A grievance is any expression of dissatisfaction expressed by you or your authorized representative through the grievance process. For example, if you believe that we have discriminated against you, you can file a grievance. Please refer to your Evidence of Coverage or Certificate of Insurance or speak with a Member Services representative for the dispute-resolution options that apply to you. You may submit a grievance in the following ways:
• By phone: Call member services at 1-800-464-4000 (TTY 711) 24 hours a day, 7 days a week (except closed holidays).
• By mail: Call us at 1-800-464-4000 (TTY 711) and ask to have a form sent to you.
• In person: Fill out a Complaint or Benefit Claim/Request form at a member services office located at a Plan Facility (go to your provider directory at kp.org/facilities for addresses)
• Online: Use the online form on our website at kp.org
Please call our Member Service Contact Center if you need help submitting a grievance. The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to discrimination on the basis of race, color, national origin, sex, age, or disability. You may also contact the Kaiser Permanente Civil Rights Coordinator directly at: Northern California Civil Rights/ADA Coordinator 1800 Harrison St. 16th Floor Oakland, CA 94612
Southern California Civil Rights/ADA Coordinator SCAL Compliance and Privacy 393 East Walnut St., Pasadena, CA 91188
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TTY). Complaint forms are available at hhs.gov/ocr/office/file/index.html.
Aviso de no discriminación
Kaiser Permanente no discrimina a ninguna persona por su edad, raza, etnia, color, país de origen, antecedentes culturales, ascendencia, religión, sexo, identidad de género, expresión de género, orientación sexual, estado civil, discapacidad física o mental, fuente de pago, información genética, ciudadanía, lengua materna o estado migratorio.
La Central de Llamadas de Servicio a los Miembros brinda servicios de asistencia con el idioma las 24 horas del día, los 7 días de la semana (excepto los días festivos). Se ofrecen servicios de interpretación sin costo alguno para usted durante el horario de atención, incluido el lenguaje de señas. Se ofrecen aparatos y servicios auxiliares para personas con discapacidades sin costo alguno durante el horario de atención. También podemos ofrecerle a usted, a sus familiares y amigos cualquier ayuda especial que necesiten para acceder a nuestros centros de atención y servicios. Puede solicitar los materiales traducidos a su idioma sin costo para usted. También los puede solicitar con letra grande o en otros formatos que se adapten a sus necesidades sin costo para usted. Para obtener más información, llame al 1-800-788-0616 (TTY 711).
Una queja es una expresión de inconformidad que manifiesta usted o su representante autorizado a través del proceso de quejas. Por ejemplo, si usted cree que ha sufrido discriminación de nuestra parte, puede presentar una queja. Consulte su Evidencia de Cobertura (Evidence of Coverage) o Certificado de Seguro (Certificate of Insurance), o comuníquese con un representante de Servicio a los Miembros para conocer las opciones de resolución de disputas que le corresponden.
Puede presentar una queja de las siguientes maneras:
• Por teléfono: Llame a servicio a los miembros al 1-800-788-0616 (TTY 711) las 24 horas del día, los 7 días de la semana (excepto los días festivos).
• Por correo postal: Llámenos al 1-800-788-0616 (TTY 711) y pida que se le envíe un formulario.
• En persona: Llene un formulario de Queja Formal o Reclamo/Solicitud de Beneficios en una oficina de servicio a los miembros ubicada en un Centro de Atención del Plan (consulte su directorio de proveedores en kp.org/facilities [haga clic en “Español”] para obtener las direcciones).
• En línea: Use el formulario en línea en nuestro sitio web en kp.org/espanol.
Llame a nuestra Central de Llamadas de Servicio a los Miembros si necesita ayuda para presentar una queja.
Se le informará al Coordinador de Derechos Civiles de Kaiser Permanente (Civil Rights Coordinator) de todas las quejas relacionadas con la discriminación por motivos de raza, color, país de origen, género, edad o discapacidad. También puede comunicarse directamente con el coordinador de derechos civiles de Kaiser Permanente en:
Northern California Civil Rights/ADA Coordinator 1800 Harrison St. 16th Floor Oakland, CA 94612
Southern California Civil Rights/ADA Coordinator SCAL Compliance and Privacy 393 East Walnut St., Pasadena, CA 91188
También puede presentar una queja formal de derechos civiles de forma electrónica ante la Oficina de Derechos Civiles (Office for Civil Rights) en el Departamento de Salud y Servicios Humanos de los Estados Unidos (U.S. Department of Health and Human Services) mediante el Portal de Quejas Formales de la Oficina de Derechos Civiles (Office for Civil Rights Complaint Portal), en ocrportal.hhs.gov/ocr/portal/lobby.jsf (en inglés) o por correo postal o por teléfono a: U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TTY). Los formularios de queja formal están disponibles en hhs.gov/ocr/office/file/index.html (en inglés).


(Evidence of Coverage) (Certificate of Insurance)

724
•

Northern California
(Office for Civil Rights Complaint Portal)
(U.S. Department of Health and Human Services) (Office for Civil
Rights) ocrportal.hhs.gov/ocr/portal/lobby.jsf
U.S. Department of Health and Human Services, 200 Independence Ave. SW,
Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TTY)
hhs.gov/ocr/office/file/index.html
Thông Báo Không K Th
Kaiser Permanente không phân bit i x da trên tui tác, chng tc, sc tc, màu da, nguyên quán,
hoàn cnh vn hóa, t tiên, tôn giáo, gii tính, nhn dng gii tính, cách th hin gii tính, khuynh
hng tình dc, gia cnh, khuyt tt v th cht hoc tinh thn, ngun tin thanh toán, thông tin di
truyn, quc tch, ngôn ng chính, hay tình trng di trú.
Các dch v tr giúp ngôn ng hin có t Trung Tâm Liên Lc ban Dch V Hi Viên ca chúng tôi
24 gi trong ngày, 7 ngày trong tun (ngoi tr ngày l). Dch v thông dch, k c ngôn ng ký hiu,
c cung cp min phí cho quý v trong gi làm vic. Các phng tin tr giúp và dch v b sung
cho nhng ngi khuyt tt c cung cp min phí cho quý v trong gi làm vic. Chúng tôi cng có
th cung cp cho quý v, gia ình và bn bè quý v mi h tr c bit cn thit s dng c s và
dch v ca chúng tôi. Quý v có th yêu cu min phí tài liu c dch ra ngôn ng ca quý v. Quý
v cng có th yêu cu min phí các tài liu này di dng ch ln hoc di các dng khác áp
ng nhu cu ca quý v. bit thêm thông tin, gi 1-800-464-4000 (TTY 711).
Mt phàn nàn là bt c th hin bt mãn nào c quý v hay v i din c y quyn ca quý v
trình bày qua th tc phàn nàn. Ví d, nu quý v tin rng chúng tôi ã k phân bit i x vi v, quý
v có th n phàn nàn. Vui lòng tham kho Chng T Bo Him (Evidence of Insurance) hay
Chng Nhn Bo Him (Certificate of Insurance), hoc nói chuyn vi mt nhân viên ban Dch V
Hi Viên bit các la chn gii quyt tranh chp có th áp dng cho quý v.
Quý v có th np n phàn nàn bng các hình thc sau ây:
• Qua in thoi: Gi cho ban dch v hi viên theo s 1-800-464-4000 (TTY 711) 24 gi
trong ngày, 7 ngày trong tun (ngoi tr óng ca ngày l).
• Qua bu in: Gi cho chúng tôi theo s 1-800-464-4000 (TTY 711) và yêu cu c gi
mt mu n.
• Trc tip: in mt mu n Than Phin hay Yêu Cu Quyn Li/Yêu Cu ti mt vn
phòng ban dch v hi viên ti mt C S Thuc Chng Trình (xem danh mc nhà cung
cp ca quý v ti kp.org/facilities bit a ch)
• Trc tuyn: S dng mu n trc tuyn trên trang mng ca chúng tôi ti kp.org
Xin gi Trung Tâm Liên Lc ban Dch V Hi Viên ca chúng tôi nu quý v cn tr giúp np
n phàn nàn.
iu Phi Viên Dân Quyn (Civil Rights Coordinator) Kaiser Permanente s c thông báo v tt c
phàn nàn liên quan ti vic k th trên c s chng tc, màu da, nguyên quán, gii tính, tui tác, hay
tình trng khuyt tt. Quý v cng có th liên lc trc tip vi iu Phi Viên Dân Quyn
Kaiser Permanente ti:
Pasadena, CA 91188
Quý v cng có th n than phin v dân quyn vi B Y T và Nhân Sinh Hoa K
(U.S. Department of Health and Human Services), Phòng Dân Quyn (Office of Civil Rights) bng
ng in t thông qua Cng Thông Tin Phòng Ph Trách Khiu Ni v Dân Quyn (Office for Civil
Rights Complaint Portal), hin có ti ocrportal.hhs.gov/ocr/portal/lobby.jsf, hay bng ng bu in
hoc in thoi ti: U.S. Department of Health and Human Services, 200 Independence Ave. SW,
Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TTY).
Mu n than phin hin có ti hhs.gov/ocr/office/file/index.html.
Language Assistance
24 hours a day, 7 days a week.
You can request interpreter
day, 7 days a week (closed
holidays). TTY users call 711.
:Arabic
.
4000-464-800-1 .
) (.
(.711 )
Armenian:
` 24 ,
7 :
,

:
` 1-800-464-4000 `
24 ` 7 ( ): TTY-
711:
Chinese: 7 24

7
711
:Farsi 7 24
.

7 24.
4000-464-800-1) (
. 711 TTY .
Hindi: , 24 ,

,
,
1-800-464-4000 , 24
, ( )
TTY 711
Hmong: Muajkwc pab txhais lus pub dawb rau koj,
24 teev ib hnub twg, 7 hnub ib lim tiam twg. Koj thov
tau cov kev pab txhais lus, muab cov ntaub ntawv
txhais ua koj hom lus, los yog ua lwm hom.Tsuas hu
rau 1-800-464-4000, 24 teev ib hnub twg, 7 hnub ib
lim tiam twg (cov hnub caiv kaw). Cov neeg siv
TTY hu 711.
Khmer: 24
7 1-800-464-4000 24 7 ( ) TTY 711
Korean:
.
,
.
1-800-464-4000
Laotian:
, 24 , 7 .
,
1-800-464-4000, 24
, 7 ().
TTY 711.
Navajo: Saad bee áká’a’ayeed náhóló t’áá jiik’é,
naadiin doo bib’ díí’ ahéé’iikeed tsosts’id yiskjí
damoo ná'ádleehjí. Atah halne’é áká’adoolwoígíí jókí,
t’áadoo le’é t’áá hóhazaadjí hadily’go, éí doodaii’
nááná lá a’ ádaat’ehígíí bee hádadilyaa’go. Kojí
hodiilnih 1-800-464-4000, naadiin doo bib’ díí’
ahéé’iikeed tsosts’id yiskjí damoo ná’ádleehjí
(Dahodiyin biniiyé e’e’aahgo éí da’deelkaal).
TTY chodeeyoolínígíí kojí hodiilnih 711.
Punjabi: , 24 , 7 ,

,
,
1-800-464-4000 , 24 ,
7 ( ) TTY
711 ‘
Russian:
24 , 7 .
,
1-800-464-4000,
24 , 7
( ). TTY
711.
Spanish: Contamos con asistencia de idiomas sin costo
alguno para usted 24 horas al día, 7 días a la semana.
Puede solicitar los servicios de un intérprete, que los
materiales se traduzcan a su idioma o en formatos
alternativos. Solo llame al 1-800-788-0616, 24 horas al
día, 7 días a la semana (cerrado los días festivos). Los
usuarios de TTY, deben llamar al 711.
Tagalog: May magagamit na tulong sa wika nang wala
kang babayaran, 24 na oras bawat araw, 7 araw bawat
linggo. Maaari kang humingi ng mga serbisyo ng
tagasalin sa wika, mga babasahin na isinalin sa iyong
wika o sa mga alternatibong format. Tawagan lamang
kami sa 1-800-464-4000, 24 na oras bawat araw, 7 araw
bawat linggo (sarado sa mga pista opisyal). Ang mga
gumagamit ng TTY ay maaaring tumawag sa 711.
Thai: 24


Vietnamese: Dch v thông dch c cung cp min
phí cho quý v 24 gi mi ngày, 7 ngày trong tun. Quý
v có th yêu cu dch v thông dch, tài liu phiên dch
ra ngôn ng ca quý v hoc tài liu bng nhiu hình
thc khác. Quý v ch cn gi cho chúng tôi ti s
1-800-464-4000, 24 gi mi ngày, 7 ngày trong tun
(tr các ngày l). Ngi dùng TTY xin gi 711.
Questions, Concerns, Service Request, or Dissatisfaction with Care or Service Kaiser Permanente’s goal is to provide the highest possible member satisfaction. Each physician, employee, and volunteer is responsible for creating an outstanding care experience for every member, every time. This includes responding to any concerns or dissatisfaction that you might have. Our highest priority is to resolve every concern or dissatisfaction wherever you receive care. Please ask to speak to the manager of the department if you have a question, concern, or are dissatisfied regarding the care or service you received. If you prefer to request a service, voice an issue or complaint, or file a benefit claim, you may file it with the Health Plan using the form provided here.
How to File a Grievance You can file a grievance for any issue. Your grievance must explain your issue, such as the reasons why you believe a decision was in error or why you are dissatisfied with the services you received. You must submit your grievance orally or in writing within 180 days of the date of the incident that caused your dissatisfaction. However, if you are a Medi-Cal member, you may submit your grievance at any time. You may submit a grievance in any one of the following ways indicated below: • By mail to Kaiser Foundation Health Plan: Member Case Resolution Center (For non-urgent/emergent standard grievances) P.O. Box 9390011 San Diego, CA 92193-90011 OR Expedited Review Unit (For urgent/emergent grievances when the non-urgent timeframe (a) could
seriously jeopardize your life, health, or ability to regain maximum function, (b) would, in the opinion of a physician with knowledge of your medical condition, subject you to severe pain that cannot be adequately managed without the services that are subject of the grievance or (c) a provider has told us that the matter is urgent)
P.O. Box 23170 Oakland, CA 94623-0170
• To a Member Services representative at your local Member Services Department • Orally, to the Member Services Contact Center, 24 hours a day, seven days a week,
excluding holidays English: 1-800-464-4000 Spanish: 1-800-788-0616 Chinese dialects: 1-800-757-7585 TTY: 711 • Online, through our website at kp.org
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DO NOT FILE IN PATIENT CHART
Member/Patient Name Medical Record Number
Address Street City ZIP Code
Daytime Telephone Number Alternate Telephone Number Birth Date
Name of Person Filing: (If different than above, a Statement of Authorized Representative form will be mailed to the member for completion):
Relationship Daytime Telephone Number
Department/Location and Medical Facility where issue occurred: Date Issue Occurred
Please describe the nature of the issue (attach additional sheets if needed):
Please explain how you tried to resolve this issue.
What would you consider a proper solution to this issue?
Signature Date
Name of Program Representative Facility Date Received For Program Representative Use Only
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Department of Managed Health Care Complaint Process* 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 Kaiser Foundation Health Plan at 1-800-464-4000 and use your health plan’s grievance process before contacting the department. 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 (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms, and instructions online.
* Not available to Medi-Cal members in Cal-Optima, Gold Coast Health Plan, and Partnership HealthPlan of California
If you have an issue that involves an imminent and serious threat to your health (such as severe pain or potential loss of life, limb, or major bodily function), you can contact the California Department of Managed Health Care directly at any time without first filing a grievance with us.
Please mail this form to the P.O. Boxes listed on page 7 for processing. If you prefer, you may file a grievance online at kp.org, in person at at your local Member Service office,
or by phone by calling 1-800-464-4000.
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GRIEVANCE FORM, NON-MEDICARE 09574-001 (10-20) ENGLISH, FOR SPANISH USE -201, CHINESE -202, TAGALOG -203, VIETNAMESE -204, KOREAN -205, KHMER -206, HMONG -207, RUSSIAN -208, FARSI -209, ARMENIAN -210, ARABIC -211, HINDI -213, JAPANESE -214, LAOTIAN -215, NAVAJO -216, PUNJABI -217, THAI -218
Member Grievance Form
Language Assistance Services
Questions, Concerns, Service Request, or Dissatisfaction with Care or Service
How to File a Grievance
COMPLAINT OR BENEFIT CLAIM/REQUEST FORM
Department of Managed Health Care Complaint Process*
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