Grievance Form En Español or Download & Print En Español In English LifeWorks is committed to ensuring our customers and our participants have a seamless experience with our service. As such, we recognize there are times when an employee/family member (“member”) has a less than satisfactory experience with LifeWorks. In these situations, the LifeWorks Quality Team will assist and strive to resolve any complaint within 30 days. Please complete this form to file a grievance. Grievances must be submitted within 180 calendar days following the incident or action that is the subject of the member’s dissatisfaction. You will receive an Acknowledgement that the Grievance has been received within 5 calendar days. You will receive a Statement of Grievance Resolution with 5 calendar days of a decision. All grievances will be resolved within 30 calendar days of receipt. If you need assistance to complete this form or have any questions about the grievance process, please call us at 1-800-234-5154. IMPORTANT: An interpreter is available to you at no cost. You can also get documents read to you and sent in your preferred language. For assistance, please call 1-800-234-5154. TTY/TDD: 1-800-999-3004. If you have any questions regarding the grievance process, please contact EAPQATeam@morneaushepell.com. Member Name * Member’s Date of Birth mm/dd/yyyy * Member’s Employer * How should we contact you and, if necessary, leave a message? PhoneEmailMailDo Not Contact Me Phone: Email: Mailing Address: Description of Grievance * Action you would like to have happen? * I hereby attest that the information above is true. Enter Initials to confirm. * Attention California Members: Please review the following information. 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 1-800-234-5154 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 might 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 1-888-466-2219 and a TDD line 1-877-688-9891 for the hearing and speech impaired. The department's Internet Web site www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.