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Exhibit N – Attachment III

BOARD OF SUPERVISORS

Gloria Molina First District

Yvonne Brathwaite Burke Second District

THOMAS L. GARTHWAITE, M.D. Director and Chief Medical Officer

Zev Yaroslavsky Third District

FRED LEAF Chief Operating Officer

COUNTY OF LOS ANGELES DEPARTMENT OF HEALTH SERVICES 313 N. Figueroa, Los Angeles, CA 90012

Don Knabe Fourth District

Michael D. Antonovich Fifth District

OFFICE OF MANAGED CARE 1000 S. Fremont Avenue Building A-9 East, 2nd Floor, Unit #4 Alhambra, CA 91803-1323

(626) 299-5312

Fax (626) 299-7251

Date

Dr. FN LN Address City, State, Zip Code

Dear:

This is to acknowledge receipt of your correspondence dated (date) and received by the Community Health Plan (CHP) Grievance Unit on (date) regarding (state problem). Your concerns are very important to us and we thank you for bringing this to our attention.

We are currently investigating the issue and will respond to you in writing within thirty (30) calendar days. The response that you will receive will indicate the result of our investigation and if necessary, will describe any actions taken to resolve the issue.

If you have any questions, please call me at (626) 299-5532.

Very truly yours,

Yolanda Turner Provider Grievance Coordinator Community Health Plan

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