TRICARE North - Health Net Grievance Form

View our Grievances page to find out about the grievance process. Note: Disputing a Point of Service charge should not be submitted as a grievance. Please visit our Disputing Point of Service Charges page to learn more.

Please complete as many fields as possible. Detailed information will help us research your concerns.

Important Note: This Web session will time-out after 15 minutes of inactivity for security purposes. If you do not populate the data fields or make changes to this form for 15 minutes, the submission may fail and the data you entered may be lost.

PRIVACY ACT STATEMENT

This statement serves to inform you of the purpose for collecting personal information required by Health Net Federal Services, LLC (Health Net) on behalf of the TRICARE® program, and how it will be used.

AUTHORITY: 10 U.S.C. Chapter 55; 38 U.S.C. Chapter 17; 32 CFR Part 199, and E.O.9397 (SSN), as amended.

PURPOSE: This information will be used by Health Net to collect information from you in order to process the grievance, respond to the requestor and/or take action to correct deficiencies.

ROUTINE USES: Your information may be disclosed in order to investigate waste, fraud and abuse, security, and privacy concerns. Use and disclosure of your records outside of DoD may occur in accordance with the DoD Blanket Routine Uses published at http://dpclo.defense.gov/privacy/SORNs and as permitted by their Privacy Act of 1974 as amended (5 U.S.C. 552a(b)). Any protected health information (PHI) in your records may be used and disclosed as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), and includes purposes of treatment, payment, and health care operations.

DISCLOSURE: Voluntary; if you choose not to provide your information, no penalty may be imposed, but absence of the requested information may result in administrative delays or the inability to process an individual’s request.

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Submitter Information

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If Health Net does not have written authorization on file to disclose your spouse’s health insurance information we may not be able to respond directly to you.  However, we will respond to your spouse. Your spouse may complete and submit the Authorization to Disclose form. The form may be faxed to the Grievances fax number 888-317-6155 for immediate processing with your grievance. If sent to the fax number on the form, processing may take up to 15 days.

If your child is age 18 or older (age 21 or older for Pennsylvania residents) and Health Net does not have written authorization on file to disclose your adult child’s health insurance information we may not be able to respond directly to you.  However, we will respond to your adult child. Your adult child may complete and submit the Authorization to Disclose form. The form may be faxed to the Grievances fax number 888-317-6155 for immediate processing with your grievance. If sent to the fax number on the form, processing may take up to 15 days.

If Health Net does not have written authorization on file to disclose the involved beneficiary’s health insurance information we may not be able to respond directly to you.  However, we will respond to the involved beneficiary. The beneficiary may complete and submit the Authorization to Disclose form. The form may be faxed to the Grievances fax number 888-317-6155 for immediate processing with your grievance. If sent to the fax number on the form, processing may take up to 15 days.