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 February 1, 2016;
  • 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 printable 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: 02/16
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 9
Street, Suite 500, Sacramento, CA 95814.
th
1. PERSON MAKING COMPLAINT
Name:
Address:
Phone Number:
Email:
Is someone else helping you file this complaint? Yes
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
Lack of bilingual personnel
The interpreter(s) or translator(s) skills were not good (List their names, if known)
The interpreter(s) made rude or inappropriate comments
Other: __________________________________________________
What language did you
Cantonese
Korean
Mandarin
Russian
need assistance with?
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:
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: 02/16
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 9
Street, Suite 500, Sacramento, CA 95814.
th
1. PERSON MAKING COMPLAINT
Name:
Address:
Phone Number:
Email:
Is someone else helping you file this complaint? Yes
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
Lack of bilingual personnel
The interpreter(s) or translator(s) skills were not good (List their names, if known)
The interpreter(s) made rude or inappropriate comments
Other: __________________________________________________
What language did you
Cantonese
Korean
Mandarin
Russian
need assistance with?
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:
DEPARTMENTAL USE ONLY:
Date Received:
Action Taken:
Action Outcome:
Contact Person:
Phone:
Email:
.