Grievance Request Form

For assistance with this form or questions regarding your grievance, please contact our Customer Service Department at 1-877-672-8620 (TTY 711), daily from 8 a.m. to 8 p.m. PST.

Member Name*

First NameLast Name

Member ID #*

Date of Birth*

Representation documentation for grievance requests made by someone other than enrollee:

Upload documentation showing the authority to represent the enrollee (a completed Appointment of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact the plan. You can also contact 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TTD users can call 1-877-486-2048.

Requestor's Name (if other than member)

Relationship to Member

If representing the member, please provide your address, email and telephone number below.

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email*

By providing your email address you are giving ATRIO permission to contact you.

Telephone #*

By providing your phone number, you agree and acknowledge that ATRIO may send text messages to your wireless phone number for any purpose. Message and data rates may apply. Message frequency will vary, and you will be able to Opt-out by replying “STOP", assistance can be found by texting "HELP". For more information on how your data will be handled please visit our Privacy PolicyFormat: (000) 000-0000.

Date of Incident*

Date

Please explain your concern (Be sure to include specific dates, times, individual people and place names, involved in the incident)*

Upload any supporting documentation

Maximum of 2 files. If you have multiple files, you can combine them before uploading. Do not exceed 10MB on each file.

Requestor's Signature*

Please verify that you are human*