Contracted Provider Feedback/Grievance Form

Provider Information

Provider Name *

Provider Organization/Practice *

Applicable SCC Program *

Contact Information

Please provide the contact details of the individual we should reach out to for resolving this issue.

Contact Name *

Communication Preference *

Email

Phone

Details of the Issue and Resolution Request

Date of the Issue or Concern (If Applicable)

mm/dd/yyyy

Description of the Issue *

Desired Resolution or Outcome *

Additional Comments

Supporting Documentation

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File Upload

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