Medi-Cal

Grievance and Appeal Form

Please fill out the form below and click “Submit,” then review it to make sure it is correct. When everything is correct, click “Submit” again, and the form will be sent to us. If you have any problems filling out this form, please call our Customer Service department at the numbers below.

* = Mandatory Fields

Date of Complaint:

Sunday, October 20, 2019

 
 
 
 
 
 
 
 
 
 
 
 
Please take some time to review this form to make any changes or add more information. If you have any problems filling out this form, please call our Customer Service Department at 1-888-587-8088.

Thank you for taking time to share your concerns with CalOptima. Please read your CalOptima Member Handbook for more information on your member rights, health coverage and available services.

Contact Us
New Medi-Cal Members
Pharmacy
Forms and Documents

Download the free Adobe Reader.

Materials available on this Website in PDF format may require the free Adobe Reader to view. To download Adobe Reader for free from the Adobe Website, click here.