Grievance/Complaint/ Provider Appeal Submission Form

At any time, if you need assistance or have questions about this form please dial 1888-977-2160.

Eastpointe would like to hear about any grievance/complaint/appeal that you may have. A grievance/complaint means that you are not satisfied with something about Eastpointe. Grievances/complaints can be about Eastpointe staff, an Eastpointe provider, and/or a provider's services or staff. Any member, provider, stakeholder, family member/legal guardian, or anonymous source may file a grievance/complaint. An appeal is filed by providers only related to an action taken against the provider by Eastpointe.

Please complete the information below. A customer service representative will contact you unless you indicate otherwise. NOTE: If you need assistance completing the electronic Grievance/Complaint form below or would like to have the form mailed to you, Please call the Eastpointe Grievance and Appeals Department at 888-977-2160,

Who is submitting this complaint/grievance/dispute?*

NOTE for ANONYMOUS Submissions ONLY: We will investigate your complaint; however, we will not be able to follow up with you. If you would like to hear the findings, you must report your name and information. As an alternative, IF YOU GIVE US YOUR NAME, you may ask that your name NOT BE USED when we investigate.

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Type of Grievance/Complaint/Appeal*

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Type of Insurance*

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What is the name of your agency?

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If Other Name (Not on the List), enter name of agency here

Enter First Name of Person Receiving Services

If not specific to a person receiving services, put N/A.

Enter Last Name of Person Receiving Services

If not specific to a person receiving services, put N/A.

Enter Date of Birth (If known) of person receiving services

Who is the complaint/grievance against?*

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If this is a complaint/grievance against a provider, what is the name of the provider?

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If non-contracted or oth provider/stakeholder

Please explain the reason for complaint/grievance/appeal:*

CONTACT INFORMATION

Please enter your contact information below. Please include the mailing address that you would like to receive acknowledgement about your grievance/complaint. We will write to you within 5 days to acknowledge receipt of your grievance/complaint.

Enter Your Name*

Enter Your E-mail Address*

If no valid e-mail address is available, please enter na@gmail.com

Enter Your Phone Number- Include Area Code*

We may call you to talk more about your grievance/complaint.

Mailing Address*

Street Address

Mailing Address State*

Mailing Address Zip Code*

You may attach any supporting documents here (not required)

Drag and drop files here or

Survey Received

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Send me a copy of my responses

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