Enrollee Grievance Form

If you are enrolled in a health plan that uses the HealthLink HMO or HealthLink POS network programs, you may use the Enrollee Grievance Form to document a grievance, such as the quality of service or care received, or to appeal an adverse benefit determination (i.e. claim denial). To make sure our office has the information necessary to thoroughly review the issue, please complete all fields and include specific details (physician or facility name, date of service, billed amounts, reason for submitting the form, etc.). You may mail or fax the completed form to the specified PO Box and fax number listed on the form.

If you enrolled in a health plan that uses HealthLink PPO or HealthLink OA network programs, please contact your plan benefits administrator, identified on your ID card, for questions regarding adverse benefit determinations.

Enrollee Grievance Form (82k)

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