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How do I fill this out?
To fill out the grievance procedure form, begin by writing down your name and contact information. Describe the discriminatory action you experienced in detail. Finally, state the relief or remedy you are seeking.
How to fill out the Northeast Delta Dental Grievance Procedure?
1
Identify the alleged discriminatory action you experienced.
2
Write your name, address, and contact details.
3
Describe the discrimination in detail.
4
Specify the remedy you are seeking.
5
Submit your completed grievance to the Section 1557 Coordinator.
Who needs the Northeast Delta Dental Grievance Procedure?
1
Individuals who have experienced discrimination in health care.
2
Patients who believe they were treated unfairly based on race or disability.
3
Healthcare providers who need guidance on grievance procedures.
4
Legal representatives assisting clients with discrimination complaints.
5
Community organizations advocating for equitable healthcare services.
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What are the instructions for submitting this form?
To submit the form, you can either email it to nlavery@nedelta.com or fax it to 603-223-1035. Alternatively, you can mail it to Northeast Delta Dental, One Delta Drive, Concord, NH 03301. Ensure your submission is within the required timelines for it to be considered.
What are the important dates for this form in 2024 and 2025?
Key dates related to grievances include the 60-day filing deadline for complaints and the 30-day period for investigation results. Be sure to submit any appeals within 15 days of the initial decision. This timeline is crucial for timely resolutions.
What is the purpose of this form?
The purpose of this form is to ensure that individuals have a clear process for reporting discrimination based on race, color, national origin, sex, age, or disability. It aims to provide a structured procedure for prompt investigations of complaints. By using this form, individuals can advocate for their rights within healthcare services.
Tell me about this form and its components and fields line-by-line.
- 1. Name: Your full name.
- 2. Address: Your current residential address.
- 3. Contact Information: Your phone number and email address.
- 4. Description of Incident: A detailed account of the discriminatory action.
- 5. Requested Remedy: What resolution or action you seek.
What happens if I fail to submit this form?
If you fail to submit this form, your complaint may not be formally addressed, potentially allowing discrimination to continue. You might also miss out on seeking a prompt resolution to your concerns. It is crucial to follow the submission procedures to ensure your grievance is considered.
- Missed Resolution: Failure to submit means unresolved complaints may persist.
- Ongoing Discrimination: Not filing could allow discriminatory practices to continue unchallenged.
- Ineligibility for Remedies: Without submission, you may lose the opportunity for relief.
How do I know when to use this form?
- 1. Reporting Discrimination: To report any discriminatory actions you have faced.
- 2. Seeking Resolution: To seek formal investigation and resolution for your grievance.
- 3. Documenting Health Service Issues: To document issues faced in healthcare services related to discrimination.
Frequently Asked Questions
How do I fill out the grievance procedure form?
Start by providing your personal details, then describe the issue you're reporting, and finally, state what resolution you are seeking.
Where do I submit the completed form?
After filling out the form, submit it to the designated Section 1557 Coordinator via the provided contact details.
Can I edit the PDF before submitting?
Yes, you can edit the PDF on PrintFriendly to ensure all information is accurate before submission.
What should I do if I face discrimination?
If you experience discrimination, use this grievance procedure to file a formal complaint.
How long do I have to file a grievance?
You must submit your grievance within 60 days of becoming aware of the discrimination.
Is retaliation allowed after filing a grievance?
No, it is illegal for Northeast Delta Dental to retaliate against anyone filing a grievance.
What happens after I file my complaint?
The Section 1557 Coordinator will investigate your complaint and issue a decision within 30 days.
Can I appeal the decision made by the Coordinator?
Yes, you can appeal the decision within 15 days to the Administrator or Board of Directors.
Does the grievance procedure affect my legal rights?
Using this grievance procedure does not prevent you from pursuing other legal actions.
What assistance is available for people with disabilities?
Northeast Delta Dental will provide necessary auxiliary aids or services for individuals with disabilities.
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