Complaint Appeal for Transportation Providers

Member Appeal Process

If you have filed a complaint but disagree with the resolution, you can request to have the resolution reviewed. An “Appeal” should be requested in writing to Modivcare within twenty calendar days of the complaint resolution release. An automatic receipt of the “Appeal” will be provided to the requestor. Failure to request an “Appeal” within twenty calendar days will be considered a “waiver of the right” to have the request declined.

Section 1: Transportation Provider Information (Required)

Transportation Provider Name

Complaint Number

Date of Birth

Phone Number

Street Address

Email Address

If completing the form as a representative for the Transportation Provider: (Required)

Representative Name

Relationship to Transportation Provider

Representative Phone Number

Representative Email Address

Section 2: Reason for Appeal (Required)

HIPAA Disclosure

All information and personal contact information you enter on this form will be securely transmitted to Modivcare directly and will be kept confidential to the extent required by HIPAA. By submitting your email address along with your feedback, you consent to communication by email from Modivcare. If you do not consent to email communications, please state your preferred method of communication in the comments section of this form.