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Members

File a Grievance or Appeal

 

Please click on your state to access the Grievance & Appeals Forms.

 

California


Submit a Grievance and Appeal

Medi-Cal Member Information

Commercial Member Information

 
IMR Form Other Languages Available 
ArabicPDF Icon   Armenian PDF Icon   Chinese PDF Icon  
Farsi PDF Icon   Japanese PDF Icon   Khmer PDF Icon  
Korean PDF Icon   Lao PDF Icon   Hindi PDF Icon  
Hmong PDF Icon   Punjabi PDF Icon   Russian PDF Icon  
Tagalog PDF Icon   Vietnamese PDF Icon
 
GA Form Other Languages Available 
ArabicPDF Icon   Armenian PDF Icon   Chinese PDF Icon  
Farsi PDF Icon   Khmer PDF Icon   Hmong PDF Icon  
Korean PDF Icon   Russian PDF Icon   Tagalog PDF Icon  
Vietnamese PDF Icon
 
State Fair Hearing Other Languages  
Arabic PDF Icon   Armenian PDF Icon   Chinese PDF Icon  
Farsi PDF Icon   Khmer PDF Icon   Korean PDF Icon  
Hmong PDF Icon   Russian PDF Icon  
Tagalog PDF Icon   Vietnamese PDF Icon
 

Nevada

 
Nevada Grievance and Appeals Form - Submit Online Link Icon  
Nevada Grievance and Appeals Form - Printable Form PDF Icon  
Nevada Medicaid Fair Hearing Request Form PDF Icon
Nevada Medicaid NAR Your Rights Form PDF Icon
 
Español
Formulario de quejas de Nevada - Enviar en línea Link Icon
Formulario de quejas y apelaciones de Nevada - Formulario imprimible PDF Icon
Formulario de solicitud de audiencia imparcial de Nevada Medicaid PDF Icon
Formulario de derechos de Nevada Medicaid NAR PDF Icon
 

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