Your information

Who are you?

Who is this compliant for?

Your first name

Your last name

Your member ID #

92######### or S########

Date of birth

Gender

Plan medical group

Preferred language

Email address

Daytime phone number

Evening phone number

Your primary address

City

State

ZIP code

Member information

About the member who is impacted by this complaint.

First name

Last name

Member ID #

92######### or S########

Date of birth

Gender

Plan medical group

Preferred language

Email address

Daytime phone number

Evening phone number

Primary address

City

State

ZIP code

Provider Information

About the health care provider involved in this complaint. If this section does not apply, click NEXT.

Provider first name

Provider last name

Provider NPI

Provider phone number

Provider email address

Provider street address

Provider city

Provider state

Provider ZIP code

Tell us more about your compliant.

What type of complaint is this?

Please describe your concern(s).

Are you writing about cancellation of coverage?

Please send us any supporting documentation you may have regarding this complaint/appeal. These include:

Copies of enrollee correspondence with Sharp Health Plan
Copies of proof of payment for the last paid coverage period
Copies of plan notices and correspondence received

By mail or in person

Sharp Health Plan
Attn: Appeals & Grievances
8520 Tech Way Suite 200
San Diego CA 92123

By fax

(619) 740-8572
Attn: Appeals & Grievances