COMMENTS POLICY

Please complete this form for submitting comments or concerns or for making suggestions relating to your FirstSight Vision Services, Inc. Plan, its services, personnel, offices, or any other aspect of the Plan that affects you as an enrollee. Please attach additional sheets if necessary.

Print or type in black ink.

Signature Date:  
Store Location/Number:  
Member's Name:  
Address:  
Telephone Number:  
   
Please write your comments below:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

You may return this form by mail, fax, or in person to:

FirstSight Vision Services, Inc.
Attn: Comments Administrator
1202 Monte Vista Avenue, Suite 17
Upland, CA 91786

Fax: (909) 932-0062

FirstSight will acknowledge receipt of the comments by sending a written notice of receipt to you within five days of FirstSight's receipt of these comments.

If you need assistance or have questions regarding the grievance process, please call FirstSight at
1-800-841-2790. The hearing and speech impaired may use the California Relay Service's toll-free telephone number (1-800-735-2929) (TTY) to contact FirstSight.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-800-841-2790 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatment that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line

(1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR applications forms and instructions online.

 

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