Form DMHC62-226 "Language Access Complaint Form" - California

What Is Form DMHC62-226?

This is a legal form that was released by the California Department of Managed Health Care - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the California Department of Managed Health Care;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DMHC62-226 by clicking the link below or browse more documents and templates provided by the California Department of Managed Health Care.

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Download Form DMHC62-226 "Language Access Complaint Form" - California

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State of California Health and Human Services Agency
Department of Managed Health Care LANGUAGE
ACCESS COMPLAINT FORM-English DMHC
62-226 New: 04/20
LANGUAGE ACCESS COMPLAINT FORM
Name:
Address:
Phone Number:
Email:
Is someone else helping you file this complaint?
Yes or No:
If Yes; Include their:
First Name
Last Name:
2. COMPLAINT DETAILS
Date of Incident:
Department/Agency:
Location or Address:
Language Access Issues:
(Check all that apply)
Lack of signs informing the public of translation services
Lack of forms/materials in multiple languages
The interpreter(s) or translator(s) skills were not good (List their names.
known
The interpreter(s) made rude or inappropriate comments
Other:
State of California
Health and Human Services Agency
Department of Managed Health Care
LANGUAGE ACCESS COMPLAINT FORM-English
DMHC 62-226 New: 04/20
LANGUAGE ACCESS COMPLAINT FORM
If you feel we have been unable to serve you because of language or other communication barriers,
the Department may be able to help. Please complete this form and mail to: Department of Managed
Health Care, Equal Employment Opportunity Office, 980 9th Street, Suite 500, Sacramento, CA
95814.
1. PERSON MAKING COMPLAINT
Name:
Address:
Phone Number:
Email:
Yes or No:
If Yes; include their:
Is someone else helping you file this complaint?
First Name:
Last Name:
2. COMPLAINT DETAILS
Date of Incident:
Department/Agency:
Location or Address:
(Check all that apply)
Language Access Issues:
Lack of signs informing the public of translation services
Lack of forms/materials in multiple languages
Lack of bilingual personnel
The interpreter(s) or translator(s) skills were not good (List their names,
known)
The interpreter(s) made rude or inappropriate comments
Other:___________________________________________
State of California Health and Human Services Agency
Department of Managed Health Care LANGUAGE
ACCESS COMPLAINT FORM-English DMHC
62-226 New: 04/20
LANGUAGE ACCESS COMPLAINT FORM
Name:
Address:
Phone Number:
Email:
Is someone else helping you file this complaint?
Yes or No:
If Yes; Include their:
First Name
Last Name:
2. COMPLAINT DETAILS
Date of Incident:
Department/Agency:
Location or Address:
Language Access Issues:
(Check all that apply)
Lack of signs informing the public of translation services
Lack of forms/materials in multiple languages
The interpreter(s) or translator(s) skills were not good (List their names.
known
The interpreter(s) made rude or inappropriate comments
Other:
State of California
Health and Human Services Agency
Department of Managed Health Care
LANGUAGE ACCESS COMPLAINT FORM-English
DMHC 62-226 New: 04/20
LANGUAGE ACCESS COMPLAINT FORM
If you feel we have been unable to serve you because of language or other communication barriers,
the Department may be able to help. Please complete this form and mail to: Department of Managed
Health Care, Equal Employment Opportunity Office, 980 9th Street, Suite 500, Sacramento, CA
95814.
1. PERSON MAKING COMPLAINT
Name:
Address:
Phone Number:
Email:
Yes or No:
If Yes; include their:
Is someone else helping you file this complaint?
First Name:
Last Name:
2. COMPLAINT DETAILS
Date of Incident:
Department/Agency:
Location or Address:
(Check all that apply)
Language Access Issues:
Lack of signs informing the public of translation services
Lack of forms/materials in multiple languages
Lack of bilingual personnel
The interpreter(s) or translator(s) skills were not good (List their names,
known)
The interpreter(s) made rude or inappropriate comments
Other:___________________________________________
State of California Health and Human Services Agency
Department of Managed Health Care LANGUAGE
ACCESS COMPLAINT FORM-English
DMHC 62-226 New: 04/20
What language did you need
assistance with?
Cantonese
Korean
Mandarin
Russian
Spanish
Vietnamese
Other:
Brief Description: Attach additional pages if needed.
3. LANGUAGE ACCESS COMPLAINT FORM ASSISTANCE
Did someone assist you In
completing this form?
Yes (input information below)
No (leave blank)
Name:
Organization:
Phone Number:
Email:
State of California
Health and Human Services Agency
Department of Managed Health Care
LANGUAGE ACCESS COMPLAINT FORM-English
DMHC 62-226 New: 04/20
2. COMPLAINT DETAILS
Cantonese
What language did you
Korean
need assistance with?
Mandarin
Russian
Spanish
Vietnamese
Other:___________________________________
Brief Description: Attach additional pages if needed.
3. LANGUAGE ACCESS COMPLAINT FORM ASSISTANCE
Yes (input information below)
Did someone assist you in
No (leave blank)
completing this form?
Name:
Organization:
Phone Number:
Email:
State of California Health and Human Services Agency
Department of Managed Health Care LANGUAGE
ACCESS COMPLAINT FORM-English
DMHC 62-226 New: 04/20
DEPARTMENTAL USE ONLY:
Date Received:
Action Taken:
Action Outcome:
Contact Person:
Phone:
Email:
State of California
Health and Human Services Agency
Department of Managed Health Care
LANGUAGE ACCESS COMPLAINT FORM-English
DMHC 62-226 New: 04/20
DEPARTMENTAL USE ONLY:
Date Received:
Action Taken:
Action Outcome:
Contact Person:
Phone:
Email:
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