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Exhibit N - Attachment IV

BOARD OF SUPERVISORS

First District

Second District

Third District

Fourth District

Director and Chief Medical Officer

Fifth District

Chief Operating Officer

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

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

First and Last name Address City, CA Zip Code

Dear Last name:

This is in response to your complaint dated

and received by the Community Health Plan (CHP)

Grievance Unit on

regarding

.

The CHP contacted correspondence that

on your behalf. As a result of our investigation, we received .

If you should have any further questions in regard to your .

, please contact

Thank you for bringing this matter to our attention. Your concerns are very important to us. If you are not satisfied with our findings, you have the right to appeal our findings by refer to the attached “Provider Grievance Fact Sheet” for information regarding the appeal process.

Very truly yours,

Yolanda Turner Assistant Grievance Coordinator Office of Managed Care/Community Health Plan

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