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Member Relations Grievance and Appeal Form - Kaiser Permanente

Member Relations Grievance and Appeal Form - Kaiser Permanente 2026

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The document is a grievance and appeal form from the Kaiser Foundation Health Plan of the Northwest, designed to assist members in resolving concerns related to their healthcare services. It outlines the necessary patient information required for filing a grievance or appeal, including details about the issue, requests for reimbursement or service adjustments, and instructions for submitting the completed form. Additionally, it emphasizes compliance with civil rights laws and provides information on available support services for individuals with disabilities or language barriers.

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Click ‘Get Form’ to open the Member Relations Grievance and Appeal Form in the editor.
Begin by filling out the 'Patient Information' section. Enter your name, health record number, address, date of birth, and phone number accurately.
In the 'Concern' section, specify what your grievance involves. Indicate if you are requesting reimbursement or an adjustment to an account, including the respective amounts.
If you are requesting care or service, clearly describe what is needed. Provide detailed information about your concern in the designated area, including dates and locations.
Complete the 'How can we help you?' section with specific details on how you would like Kaiser Permanente to assist you.
Sign and date the form at the bottom. If someone else will represent you, include their name and relationship to you.
Once completed, return the form via mail or fax as indicated at the bottom of the document.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How long does Kaiser take to reimburse?

Note: Claims can take about 45 days to process. If your claim was incomplete or missing information, it could take longer. If you feel your claim was wrongly denied or the amount you received was incorrect, you have the right to appeal.

How do I file an appeal with Blue Shield of California?

File online, by printing and mailing paper forms, or by calling us. Your doctor or someone representing you (usually an attorney, caretaker, or other legally authorized representative) can file an appeal on your behalf by mailing paper forms or by calling.

What is the difference between an appeal and grievance?

FILING AN INTERNAL COMPLAINT WITH KAISER MEMBER SERVICES Its your right as a patient to file a complaint with Kaiser which is required to have an internal process for member complaints and responses within 30 days.

How to file an appeal with Kaiser Permanente?

If you prefer, you may file a grievance online at kaiserpermanente.org, in person at your local Member Service office, or by phone by calling 1-800-464-4000.