logo
  • Members
    • Member Access
    • Member Services
    • Health Education
    • Member Newsletters
    • Clinical Guidelines
    • GRIEVANCE FORM
    • Behavioral Health
    • Member Community Resources
    • Review Process for Requested Services
  • Providers
    • Provider Services
    • Provider Access
    • Health Education Documents
    • HEDIS
    • COVID-19 Postcards
    • Staying Healthy Tools
    • Provider Alerts
    • Provider Newsletters
    • ADA/Anti-Fraud
    • Cultural Competency & Linguistic Resources
    • Provider Community Resources
    • New Provider Orientation
    • Review Process for Requested Services
  • CHG Plans
    • Medi-Cal
    • CommuniCare Advantage Cal MediConnect Plan
  • About
    • About CHG
    • Affiliations
    • Mission/Vision Statement
    • Message From CEO
    • Compliance
    • FDR Portal
    • Careers
logo
icon-menu
icon-search
  • Members
    icon-chevron-right
  • Providers
    icon-chevron-right
  • CHG Plans
    icon-chevron-right
  • About
    icon-chevron-right
  • Find A Provider
icon-chevron-left
icon-search
  • icon-check English
  • español
Font Size
  • A
  • A
  • A
Find A Provider
img alt
  • Member Access
  • Member Services
  • Health Education
  • Member Newsletters
  • Clinical Guidelines
  • GRIEVANCE FORM
  • Behavioral Health
  • Member Community Resources
  • Review Process for Requested Services

Filing a Grievance or Appeal

Filing a Grievance or Appeal

Grievance Forms

Online English Grievance Form

Online English Appeal Form 

Online Spanish Grievance Form

Online Spanish Appeal Form 

English Medi-Cal Grievance Form

Arabic Medi-Cal Grievance Form

Spanish Medi-Cal Grievance Form

Vietnamese Medi-Cal Grievance Form

Tagalog Medi-Cal Grievance Form

CMS Part C Coverage Reconsideration Request Form

CMS Part D Coverage Determination Request Form

Appointment of Representative Form (English)

Appointment of Representative Form (Spanish)

Your Rights - CMC

Your Rights - Medi-Cal

Your Rights - Medi-Cal (Spanish)

Your Rights - Medi-Cal (Arabic)

Your Rights - Medi-Cal (Vietnamese)

Your Rigths - Medi-Cal (Tagalog)

  • CHG Medi-Cal Member Services (800) 224-7766
  • CHG Cal MediConnect Member Services (888) 244-4430
  • TTY(855) 266-4584
  • Email info@chgsd.com
  • © Copyright 2020
  • Privacy Practice
  • Credits
  • Non-Discrimination Notice
  • Online Grievance Form