Grievance Process for Participants and Participant Representatives

All staff at Empath LIFE share responsibility for your care and your satisfaction with the services you receive. Our grievance procedures are designed to enable you and your family to express concerns or dissatisfaction so that we address them. At any time, should you wish to file a grievance, we will assist you or your representative. If you do not speak English, a bilingual staff member or translation service will be available to facilitate the process. LIFE services will continue during the grievance process.

A grievance is defined as a complaint or concern, which you or your representative can make either written or verbally expressing dissatisfaction with the delivery of services or the quality of care. You may also file a grievance if you believe your member rights have been violated. If your grievance cannot be resolved satisfactorily, grievance options can be pursued.

Please follow this process for filing a grievance:

1. You may discuss your grievance with any staff member at Empath LIFE. This staff member will make sure you receive written information on the grievance process and that your grievance is documented. Be sure to give complete information so they can help you resolve your grievance quickly. If you wish to register a written grievance, please send a letter to:
   Empath LIFE
   Quality Assurance
   5414 Beaumont Center Blvd.
   Tampa, FL 33634You may also contact our quality assurance coordinator at (813) 889-5000 to request
   a grievance form and receive assistance in filing a grievance. (Hearing impaired TTY
   (800) 955-8771. The coordinator will provide you with written information on the
   grievance process.
2. The staff member who receives the grievance will help you document your grievance if your grievance is not in written form and will make sure the grievance is investigated and action is taken. This information, and other information gathered during the investigation, will be kept confidential.
3. Many concerns may be easily resolved within 1-2 business days. In that case, you will receive a copy of the grievance form including a description of the resolution and the grievance will be considered resolved.
4. If the grievance cannot be resolved during that timeframe, you will receive a letter within five business days that the grievance has been received and the team is discussing plans of action regarding your grievance.
5. The staff will find a resolution within 30-calendar days of receipt of your grievance. If you are not satisfied with that resolution, you or your representative has the right to seek further action. You must contact the Empath LIFE executive director in writing no later than 20 days after you receive notification if you seek further action.
6. If the grievance involves an imminent and serious threat to your health, including but not limited to potential loss of life, limb, or major bodily function, severe pain, or violation of your member rights, we will quickly review and investigate your grievance and provide you with a decision within three days of receiving your request. In this case you will receive a telephone call to inform you that your request has been received. We will also remind you that you have the right to notify the Department of Children and Family Services Office of Hearing and Appeals (Fair Hearing Process).

Grievance Review Options:
If, after completing the grievance process, or participating in the process for at least 30-calendar days, you and your representative are still dissatisfied, you may pursue further steps. (NOTE: If the situation involves an imminent and serious threat to your health, you need not complete the entire grievance process nor wait 30-calendar days). Your grievance review options are:

At any time during the grievance process, you may contact the Department of Children and Family Services, Office of Hearing and Appeals, by contacting the:

Department of Children and Family Services,
Office of Hearing and Appeals
1317 Winewood Blvd., Bldg 5, Room 203
Tallahassee, FL 32399-0700
Telephone Number: (850) 488-1429

Participant Representative

Click on this link to learn how to appoint a representative CMS Form 1696.

(Selecting this link above may take you to another website outside of the website you are currently on.)

Send this form to the same location where you are sending (or have already sent) your appeal if you are filing an appeal, grievance or complaint if you are filing a grievance or complaint, or an initial determination or decision if you are requesting an initial determination or decision.

If you are in need of additional assistance, contact either
1-800-MEDICARE (1-800-633-4227) or your Medicare plan.
TTY users please call 1-877-486-2048