Last Name
First Name
MI
Patient name (if different than above):
Patient Date of Birth:
Relationship to Patient:
Email Address:
Phone Number:
Are you a Medi‐cal Managed Care Patient?: —Please choose an option—YesNo
If so, which plan?: —Please choose an option—Anthem Blue CrossCalViva Health NetN/A
Please select one: —Please choose an option—Scheduled AppointmentWalk In
Name of Staff(s) Involved: (if different than above):
Please check which clinic the grievance occurred: —Please choose an option—ClovisBullardBehavioral Health ServiceTachiPratherNorth Fork
Please check department(s) involved: Medical Front OfficeMedical Back OfficeDental Front OfficeDental Back OfficeReferralsBillingOpticalPRCOutreachNutritionCOVID Team
Date, Time & Describe reason for grievance:
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