Grievance Request Form

For assistance with this form or questions regarding your grievance, please contact our Customer Service Department at 1-877-672-8620 (TTY 711), daily from 8 a.m. to 8 p.m. PST.

Requester's Contact Information

Requestor's Full Name *

Requester's Telephone Number *

Requester's Email *

Representation documentation for grievance requests made by someone other than enrollee:

Upload documentation showing the authority to represent the enrollee (a completed Appointment of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact the plan. You can also contact 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TTD users can call 1-877-486-2048.

Member Information

Member Full Name *

Member's Telephone Number *

Member's Email Address

Member ID # *

Member's Date of Birth *

Location and Contact Information

Street Address *

Street Address Line 2

City *

Zip Code *

Date of Incident *

Please list the parties this grievance is about: *

Please explain your concern *

Upload any supporting documentation

Y0084_GR_09_2025_C (Updated 10/8/2025) Online

Grievance Request Form

Company

Resources

Compliance at ATRIO

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