Member Name
Member ID#
Member Telephone	Area Code - Phone Number Extension
Member Date of Birth
Person Filing Grievance (If other than member)
Address (If other than member)
Telephone (If other than member)	Area Code - Phone Number Extension
Grievance Involves (Check all that apply)	PhysicianHospital/Staff Dentist/StaffDurable Medical Equipment Supplier Nurse Practitioner/P.A.Nursing Home/Staff Optometrist/StaffHome Health Physician's Support StaffChiropractor/Staff PharmacySCAN Staff SCAN Benefits
Other
Who was involved?
What is the issue or concern?
Where did the concern occur?
Specify dates when concern(s) occurred? (If unsure please give approximate dates)

We suggest you print a copy of this form for your records.

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QUESTIONS?:
You can find detailed information regarding the Grievance and Appeal process in your Evidence of Coverage booklet.

If you have a question about what type of complaint process to use please call Member Services at 1-888-540-7226, 8:00 am - 8:00 pm, 7 days a week. TTY users should call 711.

You may also file your Grievance by Mail. Simply write us a letter, include the same information noted above and mail to:

SCAN Health Plan Arizona
1313 E. Osborn Rd.
Suite # 150
Phoenix, AZ 85014
Attn: Grievance and Appeals Department

CMS# 062503 © 2003 SCAN - SCAN 75-2003