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Member Grievance Form

Once you have submitted your form, you will receive an acknowledgement letter within five (5) calendar days and a resolution letter within thirty (30) calendar days.

* The files below are in PDF format (icon pdf)

Member Grievance Form, English
Member Grievance Form, Arabic
Member Grievance Form, Spanish
Member Grievance Form, Chinese
Member Grievance Form, Hmong
Member Grievance Form, Russian
Member Grievance Form, Vietnamese

Adobe Acrobat Reader is required to view the file(s) above. Download a free version.

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Molina now offers Medicare plans that provide all of the benefits covered under original Medicare and more.