Grievance Reporting Sample Clauses
Grievance Reporting. I acknowledge that I have been informed of the procedure to report a grievance should I become dissatisfied with any portion of my home care experience. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call (▇▇▇) ▇▇▇-▇▇▇▇ or toll free (▇▇▇) ▇▇▇-▇▇▇▇ and ask to speak to the Arrow Health Solutions Operations Manager. If your complaint is not resolved to your satisfaction within 5 working days, you may initiate a formal grievance, in writing and forward it to the Vice President of Arrow Health Solutions, LLC. You can expect a written response within 7 working days of receipt. I acknowledge I have received, read, and understand the policies outlined in the Arrow Health Solutions Disclosure Packet. I understand Arrow Health Solutions has the right to change the packet without notice. It is understood that future changes in policies and procedures will supersede or eliminate those found in this packet, and that patients and their responsible parties will be notified of such changes through normal communication channels. Please initial and sign to acknowledge receipt of the following forms: Signed Date Relationship to AHS Member Medicaid Number: DOB: Previous Provider(s): Effective Date of Change: Primary Care Physician: Phone Number: Primary Care Fax: Specialist Name: Phone Number:
Grievance Reporting. I acknowledge that I have been informed of the procedure to report a grievance should I become dissatisfied with any portion of my home care experience. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call ▇▇▇.▇▇▇.▇▇▇▇ and speak to the Customer Service. I will be notified within five (5) calendar days that Atos Medical Inc has received the complaint. With 14 calendar days of Atos Medical, Inc. receiving the complaint or receiving the returned product (whichever is later as applicable), I shall be provided written notification the results of the investigation and response. For all Atos Medical AB (Sweden) products, a response may take up to four weeks from receiving the returned product.
Grievance Reporting. Provider shall submit Managed Care Team Grievance Tracking form 8 when grievances are filed.
Grievance Reporting. I acknowledge that I have been informed of the procedure to report a grievance should I become dissatisfied with any portion of my home care experience. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call ▇-▇▇▇-▇▇▇-▇▇▇▇ and speak to the Arrow Health Solutions Revenue Cycle Manager. If your complaint is not resolved to your satisfaction within 5 working days, you may initiate a formal grievance, in writing and forward it to the Vice President of Arrow Health Solutions, LLC. You can expect a written response within 7 working days of receipt. Signed: Date: Relationship to Beneficiary: Name(s): _ Primary Address: Phone: cell home Email: _ Mailing Address: (if different than physical address) Name: _ Medicaid # DOB: _ M/F SS # - - Height _ Weight Agency _ Date Level of Care B M I _ Prior DME Ins Company _ Point of Care Specialist Region Name of Medicaid Beneficiary Medicaid # DOB Social Security # Previous Providers(s) Effective Date of Change Primary Care Physician Phone # Primary Care Fax Specialist Phone # Specialist Fax Specialist Phone # Specialist Fax By signing below, I authorize Arrow Health Solutions to provide DME/Medical Supplies according to the effective date of change for the above stated Medicaid Beneficiary. Signature Date Relationship to Beneficiary