AHCA: Subscriber Assistance Program

Search AHCA:

Site Navigation

Subscriber Assistance Program Survey

If you have participated in our Program, please complete this form and let us know about your experience with the appeal process.

Name:

Address:

Grievance/Appeal#

Grievance/Appeal Filed Against

Reason for grievance:

1. When did you file your grievance?

When were you advised of the outcome of your grievance?

2. How did you find out about the program?
Friend Newspaper Attorney Health Care Practitioner
Health Plan Other

3. Were you given a brochure about the grievance process?	Yes	No
4. Was the grievance process clearly explained to you?	Yes	No
5. Did you receive acknowledgement of receipt of your grievance by the Agency?	Yes	No
6. Did you request status reports on your grievance?	Yes	No
7. If so, did you receive them?	Yes	No
8. Were you treated in a courteous, professional manner when you contacted the staff of the Agency?	Yes	No
9. Were you given enough time and opportunity to explain your grievance to the program (panel)?	Yes	No

Additional comments: