Grievance form

If you would like to file a grievance, please review our grievance notification (82 KB PDF) and complete the form below.

If you need help filling out the form, contact Customer Service. The information you submit is private and will only be used for your grievance process.

Note: Fields shown in bold are required.

Grievance Procedure Notification And Form
Member Name
Contract Number
Person Completing Form If Other Than Member
Address
City
State
Zip
Work Phone
Home Phone
Was service authorized by your Primary Care Physician?
Is the service or treatment listed under the limitations or exclusion sections (7&8) of your certificate of coverage (COC) or any riders included with your COC?
Outline the facts pertaining to this grievance
Outline the action requested and describe the rationale which supports your position.
We encourage you to submit any additional information that you would like the Grievance Committee to consider during the review of your grievance. Additional information should be mailed to: Grievance Coordinator, MS 1145 Priority Health PO BOX 269 Grand Rapids, MI 49501-0269 Or fax it to: 616 975-8894
IMPORTANT! Please indicate if you will be sending any additional information for your grievance.  Yes.  I will be sending additional information that I would like the Grievance Committee to review.  No.  I will not be sending any additional information.
Once we receive your grievance form, we are required to begin the grievance process immediately unless you tell us to delay the process. You may wish to delay the process for any reason including to allow time for you to submit additional information. Please answer the following.
Would you like us to delay the grievance process?  Yes.  No.  (skip the acknowledgement section below)
I would like to delay the grievance process because:  I will be sending additional information  Other
I would like you to end the delay when:  You receive the additional information I am mailing  You receive the additional information I am faxing  When I call you  Other
ACKNOWLEDGEMENT I understand that Priority Health will complete a thorough investigation of my grievance for review by the Grievance Committee. I understand that this may involve contacting appropriate providers to gather relevant medical records including claims information relating to diagnosis, prognosis and treatment for physical and mental illness, mental health, substance abuse, communicable diseases, serious communicable diseases and infections, and other conditions, ailments, sicknesses and diseases, including human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS). Priority Health is committed to maintaining the confidentiality of the information that you send to us. Our grievance e-mail form is using advanced data encryption to send your information in a secure manner to Priority Health. Please click here to read more about Priority Health's committment to the privacy of your personal information.

You'll need Adobe® Reader software to view and print PDF files. Download it free now!