Grievance Request Form

For assistance with this form or questions regarding your grievance, please contact our Customer Service Department at 1-877-672-8620 (TTY 711), daily from 8 a.m. to 8 p.m. PST.

Member Full Name *

Member ID # *

Date of Birth *

Representation documentation for grievance requests made by someone other than enrollee:

Upload documentation showing the authority to represent the enrollee (a completed Appointment of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact the plan. You can also contact 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TTD users can call 1-877-486-2048.

Are you contacting us on behalf of someone else? *

Yes
No

Requestor's Full Name *

Relationship to Member *

If representing the member, please provide YOUR address, email and telephone number below.

Street Address *

Street Address Line 2

City *

Zip Code *

Email *

Date of Incident *

Telephone # *

Please explain your concern *

Upload any supporting documentation

Grievance Request Form

Company

Resources

Compliance at ATRIO

Disclosures