Grievance Form

Metropolitan Life Insurance Company

MetLife Health Plans, Inc.

Please complete this form and return it to MetLife at the address listed below to enable prompt resolution of your
complaint. MetLife will send you an acknowledgement letter within five (5) days of receipt of this form. MetLife will
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review your complaint and send you written notice of the determination within thirty (30) days of receipt of this form.

Member’s Name: Family ID Number:

Member’s Home Address:
City: State: Zip:
Member’s Home Phone No: Work Phone No:
Patient’s Name: Relationship to Member:
Patient’s Home Phone No: Work Phone No:
Employer’s Name: Employer’s Group Number:
Dental/Vision Facility Name: City:

If you need assistance in completing this form, please contact the Customer Service Department at 800.880.1800.
You may also refer to your Evidence of Coverage for a detailed description of the complaint process.

I authorize the release and disclosure of any and all of my dental/vision records to MetLife, Quality Management
Department.

Signature: Date:

Please state your complaint on the reverse side of this document, or attach a separate form and mail the completed
form to:
MetLife
c/o Quality Management Department
P. O. Box 3532
Laguna Hills, CA 92654-3532

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Residents of NY, we will provide a written response to your complaint within fifteen (15) business days of receipt.
SHP-CF-National Form Revised 9/16
 Grievance Form
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SHP-CF-National Form Revised 9/16

 Grievance Form
LANGUAGE ASSISTANCE PROGRAM: NOTICE TO INSUREDS

If you, or someone you’re helping, have questions about the MetLife Pediatric Dental
Essential Health Benefit Plan, you have the right to get help and information in your
language at no cost. To arrange for language assistance services, call (800) 880-1800.

Si usted, o alguien que está ayudando, tiene preguntas sobre MetLife Pediatric Dental
Essential Health Benefit Plan (Plan de Beneficios de Salud de MetLife Odontología
Pediátrica Esencial), usted tiene el derecho a obtener ayuda e información en su
idioma sin costo alguno. Para coordinar los servicios de ayuda con el idioma, llame al
(800) 880-1800.

如果您或您提供协助的某人有关于MetLife Pediatric Dental Essential Health Benefit

Plan（大都会人寿小儿牙科基本健康福利计划）的问题，您有权免费获得以您的母语提
供的帮助和信息。要安排语言协助服务，请致电（800）880-1800。

Nếu quý vị hoặc ai đó mà quý vị đang giúp đỡ, có thắc mắc về MetLife Pediatric
Dental Essential Health Benefit Plan (Chương Trình Phúc Lợi Y Tế Thiết Yếu Nha
Khoa Trẻ Em của Metlife), quý vị có quyền nhận miễn phí trợ giúp và thông tin theo
ngôn ngữ của quý vị. Để sắp xếp cho các dịch vụ hỗ trợ ngôn ngữ, xin gọi số (800)
880-1800.

귀하 또는 귀하께서 돕고 있는 누군가가MetLife Pediatric Dental Essential Health

Benefit Plan (메트라이프 필수 소아 치과 건강보험)에 관해서 궁금해 한다면,
귀하께서는 귀하의 언어로 무료로 도움과 정보를 제공 받으실 권리가 있습니다. 언어
통역 서비스를 이용하시려면 (800) 880-1800으로 전화하십시오.

MetLife Pediatric Dental Essential ‫ﺇﺫﺍ ﻛﻧﺕ ﻟﺩﻳﻙ ﺃﻧﺕ ﺃﻭ ﺍﻟﺷﺧﺹ ﺍﻟﺫﻱ ﺗﺳﺎﻋﺩﻩ ﺃﻱ ﺳﺅﺍﻝ ﺑﺧﺻﻭﺹ‬
‫ ﻓﻳﺣﻕ ﻟﻙ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﺍﻟﻣﺳﺎﻋﺩﺓ‬،(‫ )ﺧﻁﺔ ﻣﻳﺗﻼﻳﻑ ﺍﻷﺳﺎﺳﻳﺔ ﻟﻠﻣﺯﺍﻳﺎ ﺍﻟﺻﺣﻳﺔ ﻷﺳﻧﺎﻥ ﺍﻷﻁﻔﺎﻝ‬Health Benefit Plan
.(800) 880-1800 ‫ ﺍﻟﺭﺟﺎء ﺍﻻﺗﺻﺎﻝ ﻋﻠﻰ ﺍﻟﺭﻗﻡ‬،‫ ﻟﺗﺭﺗﻳﺏ ﺧﺩﻣﺎﺕ ﺍﻟﻣﺳﺎﻋﺩﺓ ﺑﻠﻐﺗﻙ‬.‫ﻭﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺑﻠﻐﺗﻙ ﺩﻭﻥ ﺃﻱ ﺗﻛﻠﻔﺔ‬

Si ou, oubyen yon moun w ap ede, genyen kesyon sou MetLife Pediatric Dental
Essential Health Benefit Plan (Plan Benefis Sante Dantè Esansyèl Pedyatri MetLife)
ou gen dwa resevwa èd ak enfòmasyon nan pwòp lang paw san peye anyen. Pou
aranjman asistans sèvis lang, rele (800) 880-1800.

Si vous-même, ou une personne que vous aidez, avez des questions concernant le
MetLife Pediatric Dental Essential Health Benefit Plan (Programme de Prévoyance
d’Urgence pour la Santé Dentaire des Enfants), vous êtes en droit d’obtenir
gratuitement une assistance et ces informations dans votre langue maternelle. Pour
contacter les services de traduction, appelez le (800) 880-1800.

Jeśli Ty, lub osoba, której udzielasz pomocy, ma pytania odnośnie planu MetLife
Pediatric Dental Essential Health Benefit Plan (Podstawowy plan świadczeń
zdrowotnych MetLife obejmujący pomoc pediatryczną i stomatologiczną), przysługuje
wam prawo do otrzymania informacji lub pomocy w ojczystym języku bez żadnych
SHP-CF-National Form Revised 9/16
 Grievance Form
kosztów. Aby skorzystać z pomocy językowej, prosimy dzwonić pod nr (800) 880-
1800.

Если у Вас или у кого-то, кому Вы помогаете, есть вопросы по поводу MetLife
Pediatric Dental Essential Health Benefit Plan (Базовый педиатрический
стоматологический медицинский страховой план Метлайф), у Вас есть право
получить помощь и информацию на родном языке бесплатно. Для получения
услуг языковой помощи позвоните (800) 880-1800.

Kung ikaw o ang tinutulungan mo, ay mayroong mga tanong tungkol sa MetLife
Pediatric Dental Essential Health Benefit Plan (Plan ng Mga Benepisyo para sa Mga
Mahalagang Bagay sa Kalusugan ng Ngipin na mula sa MetLife), mayroon kang
karapatang humingi ng tulong at impormasyon na nasa wika mo at nang wala kang
babayaran. Para ayusin ang mga serbisyo para sa tulong sa wika, tumawag sa (800)
880-1800.

Wenn Sie oder jemand, dem Sie helfen, Fragen zum MetLife Pediatric Dental
Essential Health Benefit Plan (Allgemeinen Pädiatrisch-zahnärztlichen
Krankenversicherungsplan von MetLife) haben, so stehen Ihnen kostenlos Hilfe und
Information in Ihrer Sprache zu. Um Sprachunterstützung anzufordern, rufen Sie bitte
(800) 880-1800 an.

MetLife保険の小児歯科エッセンシャルヘルス・ベネフィット・プランに関してご質問
がある場合は、お客様の母国語でのサポートを無料で受けることができます。母国語
でのサポートを必要となさる場合は、
(800) 880-1800までお電話くださいますようお願いいたします。

Se você ou alguém a quem você estiver ajudando tiver alguma dúvida sobre o MetLife
Pediatric Dental Essential Health Benefit Plan (Plano Essencial de Benefícios Médicos
Dentarios Pediátricos da MetLife), você tem o direito de obter ajuda e informações no
seu idioma, sem nenhum custo. Para providenciar serviços de tradução ligue para
(800) 880 - 1800.

‫ ﺳﺆﺍﻻﺗﯽ ﺩﺭﺑﺎﺭﻩ ی ﻁﺮﺡ ﺑﻬﺮﻩ ﻣﻨﺪی ﺍﺯ ﻣﺰﺍﻳﺎی ﺑﻬﺪﺍﺷﺖ ﻭ ﺳﻼﻣﺖ‬،‫ﺍﮔﺮ ﺷﻤﺎ ﻳﺎ ﮐﺴﯽ ﮐﻪ ﺷﻤﺎ ﺑﻪ ﺍﻭ ﮐﻤﮏ ﻣﯽ ﮐﻨﻴﺪ‬
،‫ ﺣﻖ ﺩﺍﺭﻳﺪ ﮐﻪ ﺍﻁﻼﻋﺎﺕ ﻭ ﮐﻤﮏ ﻣﻮﺭﺩ ﻧﻴﺎﺯ ﺧﻮﺩ ﺭﺍ ﺑﻪ ﺯﺑﺎﻥ ﺑﻮﻣﯽ ﺧﻮﺩ‬،‫ ﺩﺍﺷﺘﻪ ﺑﺎﺷﻴﺪ‬MetLife ‫ﺿﺮﻭﺭی ﺩﻧﺪﺍﻥ ﮐﻮﺩﮐﺎﻥ‬
(800) 880-1800 ‫ ﺑﺎ ﺷﻤﺎﺭﻩ ی‬،‫ ﺑﺮﺍی ﺗﺮﺗﻴﺐ ﺩﺍﺩﻥ ﺧﺪﻣﺎﺕ ﻣﺴﺎﻋﺪﺗﯽ ﺯﺑﺎﻥ‬.‫ﺑﺪﻭﻥ ﭘﺮﺩﺍﺧﺖ ﻫﻴﭻ ﻫﺰﻳﻨﻪ ﺍی ﺩﺭﻳﺎﻓﺖ ﮐﻨﻴﺪ‬
.‫ﺗﻤﺎﺱ ﺑﮕﻴﺮﻳﺪ‬

Se avete domande, o se qualcuno di cui vi occupate ha domande su MetLife Pediatric

Dental Essential Health Benefit Plan (Programma Essenziale per la Salute Ortodontica
Pediatrica di Metlife), avete il diritto di ottenere assistenza e informazioni nella vostra
lingua senza costi aggiuntivi. Per richiedere assistenza in lingua, chiamate (800) 880-
1800.

SHP-CF-National Form Revised 9/16