Format Letter For Filing Complaints


Your Name
Your Address
Your City, State, Zip Code


Date


Grievance Department
Health Plan Name
Street Address
City, State, Zip Code


Policy Number
Member/Employee Name:


Dear Sir or Madam:

The purpose of this letter is to inform you of my problem with _____________[Explain the problem you are having].

My complaint concerns______________ [the reason for your complaint]. In order to solve my problem, I would like _____________ [the specific action you want the plan to take].

I look forward to your reply and a resolution of my complaint.

Sincerely,

Your Name

Enclosures [Include copies of all related records. Do not send originals.]