Medicare grievance form 2026

1. Click ‘Get Form’ to open the Medicare Grievance Form in our editor.
2. Begin by filling out the Enrollee’s Information section. Enter the enrollee's name, date of birth, address, city, state, ZIP code, phone number, and plan ID number.
3. If someone other than the enrollee is filing the grievance, complete the Requestor’s Information section. Include their name, relationship to the enrollee, address, city, state, ZIP code, and phone number.
4. Attach any necessary representation documentation if applicable. This could be a completed Authorization of Representation Form CMS-1696 or a written equivalent.
5. Select the type of grievance by checking one of the options: Medical benefits, Pharmacy benefits, or Other.
6. If expedited decisions are needed, check the appropriate box for a 24-hour review request.
7. Describe your grievance in detail and attach any additional information that may support your case.
8. Finally, ensure that you or your representative signs and dates the form before submission.

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