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CALIFORNIA FORM FOR FILING A GRIEVANCE, FORMAL COMPLAINT OR SUGGESTION
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This form is for you or your representative's use in making suggestions or filing formal complaints or grievances regarding any aspect of the Aetna Employee Assistance Program or any of its network providers. Aetna is required by law to respond to your complaints or grievances, and a detailed procedure exists for resolving these situations. If you have any questions, please feel free to call our Member Services Department at 1-888-238-6232.
Please Print or Type the Following Information:
Member Name Last Name   First Name   Middle Initial
Address Home Telephone Number (Include Area code)
City,State,Zip    Work Telephone Number (Include Area code)
Name of Subscriber Employer or Group Date of Birth (MM/DD/YYYY)

If someone other than the member is filing this grievance, please provide the following information:
Name                                                   Last Name   First Name   Middle Initial
Address Daytime Telephone Number (Include Area code)
City,State,Zip    Relationship to Member
Suggestion Complaint/Grievance
I do do not wish to file a formal complaint/grievance. Please state the nature of the suggestion or complaint/grievance, giving date(s), time(s),
person(s) and place(s) involved:


Reminder - Before submitting this form:
  • You can preview your information by reviewing your entries
  • You can make changes at any time
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    For CA Members: As a member, you may, at any time, contact the government agency that regulates health care service plans regarding grievance or appeals issues that Aetna has not resolved or has not resolved to your satisfaction.

    The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-888-238-6232 and use the health plan's grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.


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