Appointment Assistance Request Form

If you are having trouble finding a provider nearby that provides the type of care you need, or if you are having trouble getting an appointment, you can call us toll-free at 1-855-232-3596 (TTY: 711). Our Member Services staff can assist you in making an appointment. Or complete the form below.
* First Name:
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* Last Name:
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* Member ID #:
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* Telephone Number:
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* Email Address:
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What type of provider or specialist do you need? If you want an appointment with a specific provider, please give their first and last name.
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Please provide your location (the address where you are currently living):
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Do you need help arranging transportation for health care visits?
Have you already contacted us to ask for help making an appointment?
If yes, please give the date you contacted .
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You can make a formal complaint. This is also called “filing a grievance.”

Grievance Form

Submit


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