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Grievance form

If you would like to file a grievance for a non-Medicare plan, first please review the grievance process for your plan:

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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.

Priority Health is committed to maintaining the confidentiality of the information that you send to us. This grievance e-mail form is using advanced data encryption to send your information in a secure manner to Priority Health. Read more about Priority Health's commitment to the privacy of your personal information.

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.

Personal information

Member name

Contract number

Person completing form (if other than member)

Address

City

State

ZIP

Home phone

Work phone

Grievance details

Was service authorized? By whom?

Under what section of your coverage documents do you believe this service would be covered?

Outline the facts pertaining to this grievance (dates, type of service, etc.).

Outline the action you are requesting and describe the rationale which supports your position.

IMPORTANT! Let us know if you will be sending in 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.

ACKNOWLEDGMENT

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).

Last modified: 11/23/2011

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