Blue Shield of California Promise Health Plan


Please complete the following information

*REQUIRED
















Describe what happened - List the names involved, including the provider.


Have the member/guardian discussed the problem with the provider or any other person? If so, what were the results?





 

 

 

 

© 2002 - 2019 Blue Shield of California Promise Health Plan. All Rights Reserved.

Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association