Filing a Grievance or Appeal
Participants have the right to a fair and efficient process for resolving differences with Element Care, including a rigorous system for internal review by the organization and an independent system of external review. You have the right:
- To voice complaints to Element Care employees and outside representatives of your choice, free of any restraint, interference, coercion, discrimination, or reprisal by employees.
- To appeal any treatment decision by Element Care employees, or its contractors through the process described in §460.122.
If you believe that Element Care has violated your rights or discriminated against you on the basis of race, color, national/ethnic origin, religion, age, disability, sex, sexual orientation or identity, or source of payment for health care you can file a complaint in person or by mail, fax or email with the Customer Service Manager: Address: 37 Friend Street, Lynn, MA 01902 Phone: 781-715-6612 TTY: 711 Fax: 781-780-7856 Email: firstname.lastname@example.org
If you need help filing a complaint, the Customer Service Manager is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services
Address: 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201 Phone: 1-800-368-1019, 1-800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
If you need assistance in filing an appeal or grievance, or want to let someone represent you in the process, follow the instructions below:
- Make sure you have your Medicare number. Print or type your number and your name on the top of the form.
- Appoint at least one person to act on your behalf. You can name more than one. If you do, you may want to complete a form for each of them.
- You can appoint a spouse, family member, friend, lawyer or caregiver. You must name individual people. You can’t name a law firm, legal aid group or organization to represent you. It has to be a person.
- Each person you appoint needs to complete the Acceptance of Appointment section. They provide their names and state where they accept the appointment.
- The person or people you name should fill out the Waiver of Fee for Representation part of the form if he or she won’t charge you for acting on your behalf
You can access the Appointment of Representative Form Here.
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