MEMBER COMPLAINT FORM

This form must be returned for quick resolution of the complaint.
Please send form to El Paso First Health Network at 2501 N. Mesa, El Paso, Texas 79902

Member’s Name:                                                               Date of Birth:                           

(please check one box)                

Member’s ID/SS#:                                                                       CHIP                               STAR

Member’s Address:                                                                      Commercial                  HCO

Provider’s Name:                                                  

Please describe your concern or issue:                                                                                      

El Paso First will handle your complaint immediately.  El Paso First will investigate your complaint. El Paso First will reach a decision about your complaint within 30 days, and let you know in writing about the decision.  You will get a letter that tells you what was decided about your complaint and what El Paso First will do to resolve the problem.

Date Form Received:                                                                              Date Entered in System:                                                

Members Services Representative Assigned to Case:                                                                                    

Findings/Notes:                                                                                                                                                                  

Approved Member’s Request:                  Yes                       No     

Date Letter Mailed to Member:                                                                Date Entered in System:                                                

 

FORMULARIO DE QUEJA DEL MIEMBRO

Hay que devolver este formulario para que se resuelva pronto la queja. Favor de enviar el formulario a El Paso First Health Network, 2501 N. Mesa, El Paso, Texas 79902.

Nombre del Miembro:                                                              Fecha de nacimiento:                              

Núm. de Seguro Social y de identificación del Miembro:                                              CHIP     STAR

(favor de marcar una caja)

Dirección del Miembro:                                                          

Nombre del Proveedor:                                                        

Favor de describir su inquietud o problema:                                                                                 

El Paso First tramitará su queja inmediatamente. El Paso First investigará la queja. El Paso First tomará una decisión sobre la queja dentro de 30 días, y le avisará de la decisión por escrito. Usted recibirá una carta que le dice qué decisión se tomó y qué piensa hacer El Paso First para resolver el problema.

Date Form Received:                                                                              Date Entered in System:                                

Members Services Representative Assigned to Case:                                                                                    

Findings/Notes:                                                                                                                                                                  

Approved Member's Request:                 Yes                       No      

Date Letter Mailed to Member:                                                                Date Entered in System: