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180 / 190

Received

Complaint/

Date Elevated

Code

Forwarded to

ledgement

at OMC

Grievance

to Grievance

(s)

(Unit/Date)

Letter

Date

COMMUNITY HEALTH PLAN

Provider Complaint - Grievance Log

Date of Acknow-

Date Resolved Grievant Name

GRIEVANCE CODES:

11 Quality of Service

13 Miscellaneous

21 Quality of Care

Exhibit N - Attachment II

Against Facility/IPA

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