Follow these steps.

I. MEMBER IDENTIFICATION
Please complete this section as follows:
Member first and last name
Your telephone number - to allow us to reach you if we need additional information
Member ID number - This can be found on your SCAN membership card
Date of birth

If you are filing a grievance on behalf of a member and you want to receive a response to the grievance as well, please complete the following fields on the form:
Person Filing Grievance (if other than member)
Address (if other than member)
Telephone

II. GRIEVANCE INVOLVES
This identifies the type of complaint you have. You may check as many as apply.

III. GRIEVANCE DETAILS
In order for us to further assist you, we ask that you give us as much detail as possible about your concern or problem. Please answer as many of the questions that apply to your concern.

IV. WHEN FINISHED
Click the submit button to send your form to SCAN. We suggest that you print a copy for your records.

* Required Information

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)	Physician Hospital/Staff Dentist/Staff Durable Medical Equipment Supplier Nurse Practitioner/P.A. Nursing Home/Staff Optometrist/Staff Home Health Physician's Support Staff Chiropractor/Staff Pharmacy SCAN 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.

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 1-800-367-8939.

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