Member Intent to File an Appeal

This “Intent to File an Appeal” form is to request review of a decision when services are denied, reduced, or terminated and/or if there has been an inappropriate delay in service or in the Problem Resolution Process. An Appeal must be filed within 60 calendar days of the date of the Notice of Action. Expedited Appeals must be requested (verbally or in writing) within 10 calendar days. Appeals will be addressed within 30 calendar days of filing, unless expedited (i.e. waiting will jeopardize life, health or ability to maintain or regain maximum function), in which case a decision will be made no longer than 72 hours after NCBH receives the request for expedited resolution (contact the Patients’ Rights Advocate regarding Expedited Appeals). Appeals can be filed orally or in writing by the member, provider, or authorized representative with written consent at any time.

The “Intent to File a Grievance” form is only used when a client wants to express dissatisfaction about issues regarding the provision of mental health services that are not covered by an Appeal (e.g. quality of care or services; rudeness of an employee; or failure to respect a client’s rights). Both forms can be found in the provider lobby, requested from the Patients’ Rights Advocate or online. Grievances can be filed orally or in writing by the member, provider, or authorized representative with written consent at any time.

For information regarding an Appeal and/or a Grievance or to file an appeal orally please contact the Patient Rights Advocate at 530-265-1437. For more detailed information, reference the Client Problem Resolution Guide or the Nevada County Integrated MHP and DMC ODS Handbook. Written confirmation that your Grievance or Appeal was received will be sent within five calendar days.

Grievances and Appeals will be resolved within 30 calendar days of receipt. Members have 120 days from the date of the county’s written appeal decision notice to request a State Fair Hearing. Members can file for a State Fair Hearing if you filed an appeal and received an appeal resolution letter telling you that your county denied your appeal request or your grievance, appeal, or expedited appeal wasn’t resolved in time.

You can request a State Fair Hearing:

Online: https://acms.dss.ca.gov/acms/login.request.do,

In writing: California Department of Social Services State Hearings Division, P.O. Box 944243, Mail Station 9-17-37, Sacramento, CA 94244-2430

By fax: 916-651-5210 or 916-651-2789

By telephone: 1-800-743-8525 or 1-855-795-0634

I, _________________________________:

First NameLast Name

Am informing the

The Provider (enter name below)

of my request to initiate Appeal Proceedings regarding the provision of services at your facility. I understand that I will not be subject to discrimination or any other penalty for filing an Appeal. My printed information is as follows:

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Select if unhoused

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address

Email

example@example.com

Medi-Cal #

Date of Birth

MonthDayYear

I am a

Is this appeal related to a Transgender, Gender Divers, or Intersex Discrimination Grievance?

Nature of Appeal (date occurrence, location, individual(s) involved, what service was denied, reduced, or terminated and/or explain the inappropriate delay in service or in the problem resolution process:

Describe the nature of the appeal.

I filed an Expedited Appeal

Explain how a standard appeal could jeopardize your life, health, or ability to achieve, keep, or gain you maximum life functions:

Provide an explanation detailing the need for an expedited appeal.

What steps, if any, did you take to resolve the issue (whom did you talk to, when, and what response did you get):

Describe the attempted resolution of the issue.

I give permission to contact me regarding this Appeal via text message or email:

Signature*

Date

MonthDayYear