GRIEVANCE FORM

This Sterling VisionCare Form is made available to you in accordance with the Individual Membership Contract. This form gives you the opportunity to inform Sterling VisionCare of your complaints regarding the services you received at VisionCare offices or otherwise regarding VisionCare. VisionCare will acknowledge your complaint within 5 calendar days and provide you with the name of the person reviewing your grievance. VisionCare will advise you of the decision within 30 days of receiving your grievance. You have the right to seek assistance from the Department of Managed Health Care 30 days after your grievance acknowledgement by Sterling VisionCare. You will find Grievance Forms in all VisionCare offices, or you may request a form by calling the VisionCare headquarters listed below. You may also file online and you may call this number if you need assistance in completing the grievance form. Grievances may be filed for at least 180 calendar days verbally or in writing following an incident or action that results in any dissatisfaction with the Plan. If you need interpretation or communication assistance due to: (1) limited English proficiency; (2) linguistic and cultural needs; or (3) communicative impairments, the Plan will then make available without charge interpreters and relay systems in order to properly assist the Member through the Plan’s grievance system. For the hearing and speech impaired, you may access the Plan by calling the CA Relay Service at 800.735.2922.

For your convenience, you may also file your grievance over the telephone by calling VisionCare headquarters at:

800.454.4647

If you chose to file a written grievance, please follow these directions:
1. Type or print all information. Be sure to include the VisionCare office location in question.
2. File this form electronically below or print and mail to VisionCare headquarters at the address listed below:

Sterling VisionCare; 9625 Black Mountain Road; Suite 306; San Diego, CA 92126

www.sterlingvisioncare.com

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 800.454.4647 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 treatments 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 application forms and instructions online.

GRIEVANCE FORM