Submit a Grievance (Complaint)
Eastpointe would like to hear about any grievance (complaint) that you may have. A grievance means that you are not satisfied
with something about Eastpointe. It can be about Eastpointe staff, an Eastpointe provider, and/or a provider’s services or staff.
Any member, provider, stakeholder, family member/legal guardian or anonymous source may file a grievance (complaint). Please
complete the information below. A customer services representative will contact you unless indicated otherwise.
If you need assistance completing the electronic Grievance (Complaint) Form below or would like to have the form mailed
to you, please call the Eastpointe Grievance and Appeals Department at 1-800-513-4002, Option #3.
I am a:
Member Receiving Services
Agency (provider, DSS, etc)
***Eastpointe staff please enter Grievances(Complaints), Compliments or Questions within Alpha. Thank You.***
I have a:
We will look into your complaint even if we do not have your name. However, we will not be able to follow-up with you.
If you give us your name, you may ask that your name not be used when we investigate.
Please tell us your first and last name:
I want my name used when investigating the complaint:
Type of Complainant
Complaint is About
Please tell us your Address. We will write to you within 5 business days to acknowledge receipt of
Please enter your phone number below, including your area code. We may call you back to talk more
about your grievance/complaint.
Please tell us your email address:
Name of person completing this form:
Please use this area to tell us all the details about your grievance (complaint)
This form is intended for the use of the person or entity to which it is addressed and may contain information that is privileged
and confidential, the disclosure of which is governed by applicable law. If the reader is not the intended recipient, or the
employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination,
distribution, or copying of this information is
. If you have received this message in error, please
notify the original sender immediately by return email, along with this form from any electronic device. Thank you.
MCO Form No:179: 1/15/2019 [Relevant Policy: Q-6.4.4]
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