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Submit a Grievance

For Minnesota Health Care Programs Members


A grievance is a formal complaint. Filing a grievance with Medica means that you would like us to address your complaint. This is not part of the appeals process; but you can submit a grievance along with an appeal and it will not affect the outcome of the appeal.

Member Information

Do you require an interpreter?
Would you like to designate someone other than the member to serve as an authorized representative for this grievance?

Authorized Representative

If you would like to designate someone other than the member to serve as authorized representative, please fill out this section.

Which Medica plan do you have?

Authorization Form

In order to act as an authorized representation, the member will need to fill out the Appointment of Representative form. You can download and complete this form, then attach it below. You also have the option to fax or mail the form, if you prefer.

Download form

Authorization Form

In order to act as an authorized representation, the member will need to fill out the Appointment of Representative form. You can download and complete this form, then attach it below. You also have the option to fax or mail the form, if you prefer.

Download form

Reason for Grievance

Attestation

I attest that:

Last Updated December 2022

H2458_1004798 Approved

Y0088_1004798_C