GET COVERED NOW GRIEVANCE FORM INDIVIDUALS GROUPS BROKERS PROVIDERS SEARCH CONTACT US GRIEVANCE FORM You are here: Home \ Forms \ Grievance Form You will receive an acknowledgement letter within 5 days of receiving your complaint by our office and who may be contacted for more information. You will be advised of the final disposition of your complaint in writing. You will receive an acknowledgement letter within 5 days of receiving your complaint by our office and who may be contacted for more information. You will be advised of the final disposition of your complaint in writing. Patient's Name Member's Name (if different from patient's name) Birthdate Member Number Plan Type Date of Service Group Name/Group # Home Phone Work Phone Address Street Address Address Line 2 City California State ZIP Code Provider Name Facility # Provider Phone Grievance Type Provider Complaint Grievance Summary To file a grievance, please contact Vision Plan of America at 1(800) 400-4VPA (4872) (hearing impared dial 711), by mail at: 3250 Wilshire Blvd., Ste. 1610, Los Angeles, CA 90010, by Fax at (213) 384-0084 or by Email at info@visionplanofamerica.com. Free Language Assistance Program If you require Language Assistance at any time including during the course of an eye examination or during the discussion of the diagnosis following an eye examination Please contact the “Plan” at 1(800) 400-4VPA. The availability of Language Assistance is FREE to members and providers. Programa de Asistencia de Idiomas Gratis Si requiere asistencia de idiomas en cualquier momento incluyendo durante el proceso de su examinación de los ojos o durante la discusión de la diagnosis después de su examinación de los ojos por favor llame al “Plan” 1(800) 400-4 VPA. La disponibilidad de asistencia de idiomas es GRATIS para miembros y proveedores. 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 800-400-4VPA (4872) (dial 711 for hearing impaired), online at www.visionplanofamerica.com, by fax at (213) 384-0084 or by mail at: 3255 Wilshire Blvd., Ste 1610, Los Angeles, CA 90010 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 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 //www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. GET COVERED NOW GRIEVANCE FORM INDIVIDUALS GROUPS BROKERS PROVIDERS SEARCH CONTACT US Providers Click Here © 2018 Vision Plan of America