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Member Grievance Form

Please fill-up the online form OR you may download and fill-up the Member Grievance Form (PDF) and mail or fax to:
Member Services Contra Costa Health Plan
595 Center Ave., Suite 100 Martinez, CA 94553
Phone: 1-877-661-6230, Press 2
Fax: 925-313-6047

Online Grievance Form

Member Name
First Name


Last Name
Date of Birth
Member ID Number
(include extension if needed)
see our privacy policy
Date of Service
Location of Service
Briefly Describe Complaint
(Please include as much detail as possible including names of the people involved, the circumstances leading up to the conflict, and any information you feel is important to the complaint)
What action are you requesting?

Person Making the Complaint if other than member

Name of Person Submitting Grievance
Relationship Spouse     Parent     Grandparent Guardian
if none of the above, please specify:

If not authorized by member or member's legal guardian, we will be unable to process grievance without member's explicit agreement.

If you experience any difficulties with this form, please contact us at 1-877-661-6230 (press 2).


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 1-877-661-6230 and use your 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 for 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.