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Complaints and Appeals

Complaint Form

* field must be filled in

Your Name *

Your Relationship to the Member Your Relationship to the Member

Your Contact Phone Number *

Do you have a completed Designated Client Representative Form (DCR)? *

Yes

This form is required for you to file a complaint on behalf of a Member 15 or older.

Member's Name *

Member's Medicaid Number

Member's Date of Birth *

Who is your complaint against?

What is your complaint? *

What is the outcome you would like?

Copyright © 2024 Carelon. All rights reserved. Member Protections
Members are protected under the Federal Mental Health Parity and Addiction Equity Act (MHPAEA). This act states that there are not more limits on your behavioral health benefits than your physical health benefits. If you feel these rights have not been upheld, you can call the Behavioral Health Ombudsman at 303-866-2789, Email them at: ombuds@bhoco.org, or go online at: behavioralhealthombudsman.colorado.gov.
Land Acknowledgement
We would like to acknowledge that the land we live, work, learn, and commune on is the original homelands of many tribal nations. We acknowledge the painful history of genocide and forced removal from this territory, and we honor and respect the many diverse Indigenous peoples still connected to this land on which we gather. To learn more about territory acknowledgement, visit native-land.ca.

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