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SOC Appeal/Grievance Form (English)

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PLACER COUNTY SYSTEMS OF CARE APPEAL/GRIEVANCE FORM

Health and Human Services Department

Note: Filing an Appeal/Grievance will not adversely affect the services you receive from Placer County Systems of Care. The client will be contacted by the QI Department within required timeframes. If you do not wish to file online, or do not have an email address to do so, please contact us at 916-787-8979 to file by phone or obtain a paper grievance form.

FILING QUESTIONS

I am filing a (check one): Check “Appeal” if you have had a service denied or reduced, and you disagree with this decision. Check “Grievance” for any other complaint. *

I am filing a (check one): Check “Appeal” if you have had a service denied or reduced, and you disagree with this decision. Check “Grievance” for any other complaint.

Appeal

Grievance

Expedited Appeal

Type of service: *

Type of service:

Mental Health

Substance Use

Name of client filing Appeal/Grievance: *

I am (check one): *

I am (check one):

Client

Acting on Client's Behalf

Other

Mailing Address:

Telephone Number: *

Phone form field Telephone Number: must be in the format: (000) 000-0000

Email *

Email form field Email is not in correct form

Please summarize the problem(s) you have using specific details. *

Please describe what you have done to try to resolve the problem:

Please make any suggestions for resolution:

If you would like information about this Appeal/Grievance to be given to anyone, please list their name(s) here:

Client Signature: *

Signature form field Client Signature: is required

Date: *

Date form field Date: must be in the format: MM/dd/yyyy

Signature of person acting on client’s behalf: *

Signature form field Signature of person acting on client’s behalf: is required

Date: *

Date form field Date: must be in the format: MM/dd/yyyy

For questions contact: Placer County Systems of Care
Quality Management Designee
101 Cirby Hills Drive
Roseville, CA 95678
Phone: 916-787-8979
Fax: 916-872-6521

Email Address: