Follow the steps to accurately complete your grievance form.

1. Press the ‘Get Form’ button to obtain the grievance form and open it for editing.
2. Begin with Section 1, which requests your member information. Fill in your name, facility ID number, and contact details including your address, home phone number, work phone number, and relationship to the patient if different.
3. In Section 2, provide the employer information. Include the employer's name, group number, and the dental or vision facility name along with its city.
4. Next, proceed to Section 3, Authorization. You must authorize the release of your dental or vision records to SafeGuard Health Plans, Inc. by signing and dating the form.
5. Clearly state the nature of your complaint on the designated space or attach a separate document with the details.
6. Once completed, mail the form to the Quality Management Department at the provided address. Be sure to keep a copy for your records.
7. Finally, you can save your changes, download, print, or share the completed grievance form as needed.

Take action today by completing your grievance form online to ensure your complaint is addressed promptly.