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If you are unhappy with anything about your care or with Care1st Health Plan, we want to know about it. We also want to hear your suggestions about how we can improve our services. Please fill out the grievance form below, Care1st Health Plan will work with you to resolve your grievance to your satisfaction. Grievance resolution will be mailed to you within 30 days.

Member Information Please fill out all of the following fields that contain important member information.

First Name
Last Name
Member #
Date of Birth
Email Address
Phone #
Street Address

City
Zip
Contact Name
Relationship
Preferred Primary Language Spoken
Provider Name


Grievance Information This information becomes part of the permanent record.

Date of Incident
Details of Incident Describe what happened -- list the names involved, including the provider.

Desired "outcome" requested

Results from previous discussion(s) Have the Member / Guardian discussed the problem with the provider or any other person? If so, what were the results?

Additional Comments


	Care1st Contact Details Care1st Health Plan Grievance Coordinator at: 601 Potrero Grande Dr Monterey Park, CA 91755 Phone: 1-800-605-2556

	State Department of Social Services Public Inquiry and Response Unit 1-800-952-5253

	State Department of Health Services - Ombudsman Unit 1-888-452-8609

	California Department of Managed Healthcare Website

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