member complaint form - El Paso First Health Plans Inc.

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ATTACHMENT 18
MEMBER COMPLAINT FORM
This form must be returned for quick resolution of the complaint. Please
send form to El Paso First Health Plans, Inc. at 2501 N. Mesa, El Paso,
Texas 79902
Member’s Name:
ID Number:
Member’s Address:
Phone #:
____________
_____________________________
Date of Birth:
____________
__________________________
Date of Service: ______________
Provider’s Name:
Claim Number:
CHIP
STAR
HCO
CHIP Perinatal
(please check one box)
Please describe your concern or issue:
_____________________________________________________________________________
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_____________________________________________________________________________
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Contact Name:
__________________________
Date:
___________________
El Paso First will handle your complaint immediately. El Paso First will investigate your
complaint. El Paso First will reach a decision about your complaint within 30 days, and let you
know in writing about the decision. You will get a letter that tells you what was decided about
your complaint and what El Paso First will do to resolve the problem.
Official Office Use Only
Date Form Received:
Date Entered in System:
Findings/Notes:
Approved Member’s Request:
Date Letter Mailed to Member:
Yes
No
Date Entered in System:
FORMULARIO DE QUEJA DEL MIEMBRO
Hay que devolver este formulario para que se resuelva pronto la queja.
Favor de enviar el formulario a El Paso First Health Plans, Inc., 2501 N.
Mesa, El Paso, Texas 79902
Nombre del Miembro:
_________________________
Fecha de nacimiento: ____________
Num. De Seguro Social y identificacion del Miembro: __________________________
Direccion del Miembro: ____________________
_______________________
CHIP
STAR
HCO
CHIP Perinatal
(favor de marcae una caja)
Nombre del Proveedor:
Fecha de servicio: ______________
Favor de escribir su inquietud o problema: _________________________________________
_____________________________________________________________________________
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_____________________________________________________________________________
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Nombre del contacto:
__________________________
Fecha: ___________________
El Paso First tramitará su queja imediatamente. El Paso First investigará la queja. El Paso First
tomara una decisión sobre la queja dentro de 30 dias, y le avisará de la decision por escrito.
Usted recibirá una carta que le dice que decisión se tomó ye que piensa hacer El Paso First para
resolver el problema.
Official Office Use Only/Sólo para uso oficial de la oficina
Date Form Received:
Date Entered in System:
Member Services Representative Assigned to Case: __________________________________________
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Findings/Notes:
Approved Member’s Request:
Date Letter Mailed to Member:
Yes
No
Date Entered in System:
Comment [dsc1]: Wording taken from the
Member’s Handbook.