Mindfully Grievance Form

Mindfully Grievance Form
Instructions for filing a grievance/appeal:

1. Fill out this form completely. Describe the issue(s) in as much detail as possible.
2. Attach any copies of any records you wish to submit. (Do Not Send Originals).
3. If you have someone else submit for you, you must give your consent below.
4. You may submit the completed form through one of the following ways:
- submit this form,
- or mail the completed form to the address listed below.
We will send a written acknowledgment letter of your grievance. It will be mailed to you within five working days after the grievance is received. Thank you.
Your Name

First NameLast Name
Name of Mindfully Client, if not you

First NameLast Name
Your relationship to the client
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mindfully Clinician's name
Specific issue(s): Please state all details relating to your request including names, dates and places.
You can extend the writing space by dragging out on the bottom right corner of the text box.
File Upload

Cancelof
Ways to submit your grievance:

Please click "SUBMIT” to submit this form, or, if you would prefer, you can complete this form, or mail it to the address below.

Compliance Department
Mindfully
10290 Alliance Rd,
Cincinnati, OH 45242

We will send a written acknowledgment letter of your grievance. It will be mailed to you within five working days after the grievance is received. Thank you.
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