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Alpine Grievance/Appeal Form 01/14/16 1 Alpine County Behavioral Health Services GRIEVANCE, STANDARD APPEAL, AND EXPEDITED APPEAL FORM As a client of Alpine County Behavioral Health Services (ACBHS), you have the right to let us know if you are unhappy or dissatisfied with any matter. For most matters, you may file a grievance. If the matter involves an action, you have the right to file an appeal. An action occurs in the following situations: • We deny or limit a service that you requested, including the type or level of service; • We reduce, suspend, or terminate a service that was previously authorized for you; • We deny all or part of payment for a service provided to you; • We fail to provide services to you in a timely manner, as determined by ACBHS; or • We fail to act within the timeframes for deciding about standard grievances, standard appeals, or expedited appeals. Please see page 2 (back) for more information about each process. Grievance Standard Appeal Expedited Appeal Name of person filing the grievance, standard appeal, or expedited appeal: Client name: Address: City: State: Zip code: Phone number: ( ) - Date of Grievance/Appeal Request: Reason for Request: Client Signature: Date: Alpine County Behavioral Health Services Grievance, Standard Appeal, and Expedited Appeal Form Page 1 of 2 Please return completed form to: Alpine County Behavioral Health Services 75 C Diamond Valley Rd. Markleeville, CA 96120 ---PAGE BREAK--- Alpine Grievance/Appeal Form 01/14/16 2 Grievance, Standard Appeal, and Expedited Appeal Processes Grievance Process: You have the right to file a grievance either verbally or in writing. If you wish, you can have someone call or write for you. We will write to you to let you know that we received your grievance. We will then review your grievance and write to you to let you know our decision within sixty (60) calendar days from the date that we received your grievance. The grievance process may last longer than sixty (60) calendar days if you request an extension, or if we decide that we need more information and that the extension is in your best interest. This extension can only last up to fourteen (14) calendar days. We will let you know if we extend the process. Standard Appeal Process (regarding actions): You have the right to file a standard appeal to request a review of an action. You may file an appeal either verbally or in writing. If you request an appeal verbally, you will need to give us a signed written appeal after you verbally tell us. You must file an appeal within ninety (90) days of the date of the action that you are appealing. You may authorize another person, including your provider, to represent you during the appeal process. We will write to you to let you know that we received your standard appeal. You have the right to present evidence in person or in writing that supports or relates to your appeal. You also have the right to look at your case file and any other records that are important to your appeal before and during the appeal process. We will review your standard appeal and write to you to let you know our decision. We will let you know our decision within forty- five (45) calendar days from the date your standard appeal was filed. The standard appeal process may last longer than forty-five (45) calendar days if you request an extension, or if we decide that we need more information and that the extension is in your best interest. This extension can only last up to fourteen (14) calendar days. We will let you know if we extend the process. Our written decision to you will include information about your right to file for a State Fair Hearing and how to do so. It will also include information about how, in certain situations, to keep your current services while you are waiting for the hearing. Medi-Cal beneficiaries: If you have completed the ACBHS problem resolution process and are not completely satisfied with our decision(s), you have a right to file for a state fair hearing. Instructions can be found in your Beneficiary Guide to Medi-Cal Mental Health Services. Expedited Appeal Process (regarding actions): You have the right to file an expedited appeal to request a review of an action. Expedited appeals are considered necessary ONLY if using the standard appeal process could jeopardize your life, health, or ability to achieve, keep, or regain your maximum life functions. You can file an expedited appeal either verbally or in writing. You may authorize another person, including your provider, to represent you during the appeal process. We will write to you to let you know that your request for an expedited appeal has been received. We will then review your request for an expedited appeal. If we deny your request for an expedited appeal, the appeal will be changed into a standard appeal and will follow the standard appeal process. We will make reasonable efforts to let you know as soon as possible if we deny your request for an expedited appeal. We will also send you written notice, within two calendar days of the date that we received your request. If we decide that your request for an expedited appeal is valid, you will have the right to present evidence in person or in writing that supports or relates to your expedited appeal. You also have the right to look at your case file and any other records that are important to your expedited appeal before and during the expedited appeal process. For Office Use Only: Access Denied Services (NOA) Change of Provider Quality of Care Confidentiality Issue HIPAA Other: Action Taken: ---PAGE BREAK--- Alpine Grievance/Appeal Form 01/14/16 3 Staff Signature: Date: