Medicare Grievance Form

Grievance or expression of dissatisfaction

You may complete and submit the form below to file a grievance. We will notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint.

Who may make a request

You (the enrollee), your provider or your representative can request a grievance. Representation documentation is required for grievance requests made by someone other than the Enrollee or the Enrollee's provider. Attach documentation showing the authority to represent the Enrollee (a completed Authorization of Representation Form CMS-1696 (PDF) or a written equivalent) if it was not already submitted at the coverage determination level. For more information on appointing a representative, contact our customer service department.