Plumas County SYSTEMS OF CARE APPEAL/GRIEVANCE FORM
Department of Behavioral Health Services

Note: Filing an Appeal/Grievance will not adversely affect the services you receive from Plumas County Systems of Care. The client will be contacted by the QI Department within required timeframes. If you do not wish to file online, or do not have an email address to do so, please contact us at 530-283-6307 to file by phone or obtain a paper grievance form.

I am filing a (check one): Check “Appeal” if you have had a service denied or reduced, and you disagree with this decision. Check “Grievance” for any other complaint*

Appeal Grievance

Expedited Appeal

Type of Service*

Mental Health Services

Substance Use Services

Name of client filing Grievance/Appeal*

I am (check one): *

Client Acting on Client's Behalf

Other

Client's Mailing Address:*

Client's Daytime Phone Number*

Email:*

Please summarize the problem(s) you have using specific details.*

Please make any suggestions for resolution:*

If you would like information about this Appeal/Grievance to be given to anyone, please list their name(s) here:

Client Signature: (Type Full Name)*