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Home > For Members > Online Self-Service > Grievance Form In-Home Supportive Services (IHSS)

Online Self-Service

Grievance Form for Alliance Care In-Home Supportive Services (IHSS)

The Alliance will acknowledge receipt of your complaint or appeal in writing within five (5) calendar days, and respond to your complaint or appeal in writing within thirty (30) calendar days.

Note: This form is for IHSS members only. All fields are mandatory.

Fields with an asterisk (*) are required.

You can have a family member or a friend help you file your complaint.

You may also contact the California Department of Managed Health Care.

California Department of Managed Health Care Statement

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 your health plan at (800) 700-3874 or TDD (800) 735-2929 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.

If you feel the Alliance or a health care provider has not respected your privacy, you have the right to file a complaint with the Department of Health and Human Services at any time by contacting:

Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue SW
Room 509F, HHH Building
Washington DC, 20201

Un miembro de su familia o una amistad puede ayudarle con su queja.

Declaración del Departamento de Atención Médica Administrada de California

El Departamento de Atención Medica Administrada de California (California Department of Managed Health Care) es responsable de regular los planes de servicio de atención médica. Si usted tiene una queja contra su plan de salud, primero debe llamar a su plan de salud al (800) 700-3874 y para las personas con dificultades de audición o del habla llaman al (800) 855-3000, y use el proceso de quejas de su plan de salud antes de comunicarse con el departamento. El uso de este proceso de quejas no le impide usar ningún posible derecho o recurso legal que pueda estar a su disposición. Si necesita ayuda con una queja que involucre una emergencia, una queja que su plan de salud no haya resuelto de manera satisfactorio o una queja que no ha resuelta por más de 30 días, puede llamar al departamento para recibir ayuda. Es posible que también cumpla los requisitos para una Revisión Médica Independiente (Independent Medical Review; IMR, por sus siglas en ingles). Si es elegible para una Revisión Médica Independiente, por medio de Revisión Médica Independiente se hará una investigación imparcial de las decisiones médicas tomadas por un plan de salud respecto a una necesidad médica de un servicio o tratamiento pospuestos, decisiones de cobertura para tratamientos de naturaleza experimental o de investigación, e inconformidad por el pago de servicios médicos de emergencia o urgencia. El departamento también tiene una línea gratuita (1-888-466-2219) y una línea TDD (1-877-688-9891) para las personas con dificultades de audición o del habla. El sitio web del departamento es www.dmhc.ca.gov y puede encontrar formularios de queja, formularios de solicitud para Revisión Médica Independiente, e instrucciones en línea.

Si considera que su confidencialidad no ha sido respetada, usted tiene el derecho de presentar una queja ante el Departamento de Salud y Servicios Humanos en cualquier momento. Presente su queja comunicándose con:

Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue SW
Room 509F, HHH Building
Washington DC, 20201

Contact Member Services

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    TTY: 800-735-2929 (Dial 711)
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Contact us | Toll free: 800-700-3874

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