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    Sutter Health Plus Forms and Resources

    Keeping our members
    informed



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    Members

    - Grievance FormOpens new window*
    - Continuity of Care Request FormOpens new window*
    - Request for Review by DMHC FormOpens new window*
    - Request for Review by Sutter Health Plus FormOpens new window*
    - Right to Submit Request for Review of Cancellation, Recession or Nonrenewal of Your Plan Contract, Enrollment or SubscriptionOpens new window*
    - Member Rights and ResponsibilitiesOpens new window
    - Pharmacy Mail Order FormOpens new window
    - Sutter Health Plus Enrollment GuideOpens new window

    *Additional Information about forms below
    View glossary of terms
    Download the uniform glossary documentOpens new window



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    Employers

    - 2017 Small Group Employer ApplicationOpens new window
    - 2017 Small Group Enrollment FormOpens new window
    - Termination FormOpens new window
    - Pharmacy Mail Order FormOpens new window
    - Sutter Health Plus Enrollment GuideOpens new window


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    Brokers

    - 2017 Small Group Employer ApplicationOpens new window
    - 2017 Small Group Enrollment FormOpens new window
    - Termination FormOpens new window
    - Individual and Family Plan Application and EnrollmentOpens new window
    - Pharmacy Mail Order FormOpens new window



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    Providers

    - Prescription Drug Prior Authorization Request FormOpens new window




    Grievance Form - If you have concerns with Sutter Health Plus or a Sutter Health Plus provider, give us a chance to help. You have the right to submit a complaint or grievance at any time. A grievance is a written or oral expression of dissatisfaction. Grievances include, but are not limited to, quality of care concerns and requests for review of coverage decisions.

    You have 180 calendar days from the date of the event that caused your dissatisfaction to submit a grievance.

    Sutter Health Plus handles all member information in a confidential manner. We do not discriminate against any member who has submitted a grievance. Please fill out the Grievance FormOpens new window or call the Sutter Health Plus Member Services Department at 855-315-5800 to file a grievance. You can submit your completed Grievance Form by mail, fax or online (after logging into the member portal). Page two of the Grievance Form has contact information for mailing or faxing your grievance.

    Continuity of Care - If you are currently receiving treatment and are (a) a new SHP member or (b) an existing SHP member whose physician is leaving or has left the SHP network, you may request to temporarily remain with your current treating physician. For more information, please review the Continuity of Care FormOpens new window.

    Request for Review Forms for Cancellations, Rescissions or Nonrenewals - If you believe Sutter Health Plus has (or will) improperly cancelled, rescinded or not renewed your plan coverage, you have the right to file a Request for Review. You may submit a request to Sutter Health Plus, the Department of Managed Health Care (DMHC) or both.

    You have 180 days from the date of the notice of cancellation or termination you received from Sutter Health Plus to submit a Request for Review. You may submit the request by mail, fax, telephone or online. To make a request, please complete the Request for Review by DMHC formOpens new window or the Request for Review by Sutter Health Plus formOpens new window.

    For more information on your rights and options, and for contact information for submitting the requests, refer to the document Right to Submit Request for Review of Cancellation, Rescission or Nonrenewal of Your Plan Contract, Enrollment or SubscriptionOpens new window. Page one of each of the forms also has contact information for submitting your request.



    - Large Group PlansOpens new window
    - Small Group PlansOpens new window
    - Individual and Family PlansOpens new window
    - Dental PlansOpens new window
    - Vision PlansOpens new window
    - Acupuncture and Chiropractic PlansOpens new window
    - Infertility and OrthoticsOpens new window



    For more information about Sutter Health Plus’ health plans, you may download and view the 2017 Evidence of Coverage for individuals, small and large groups. For assistance or if you have difficulty accessing the information you need, please contact Sutter Health Plus Member Services at 855-315-5800.

    - 2017 Individual Evidence of Coverage Plan MI01Opens new window
    - 2017 Individual Evidence of Coverage Plan MI02Opens new window
    - 2017 Individual Evidence of Coverage Plan MI03Opens new window
    - 2017 Individual Evidence of Coverage Plan MI04Opens new window
    - 2017 Small Group HMO Evidence of Coverage TemplateOpens new window
    - 2017 Small Group HMO Plus Plan Evidence of Coverage TemplateOpens new window
    - 2017 Small Group HDHP Evidence of Coverage TemplateOpens new window
    - 2017 Large Group HMO Evidence of Coverage TemplateOpens new window
    - 2017 Large Group HMO Evidence of Coverage Template for plans ML34-ML37Opens new window
    - 2017 Large Group HDHP Evidence of Coverage TemplateOpens new window


    - 2016 Individual Evidence of Coverage Plan MI01Opens new window
    - 2016 Individual Evidence of Coverage Plan MI02Opens new window
    - 2016 Individual Evidence of Coverage Plan MI03Opens new window
    - 2016 Individual Evidence of Coverage Plan MI04Opens new window
    - 2016 Small Group HMO Evidence of Coverage TemplateOpens new window
    - 2016 Small Group HDHP Evidence of Coverage TemplateOpens new window
    - 2016 Large Group HMO Evidence of Coverage TemplateOpens new window
    - 2016 Large Group HMO Evidence of Coverage Template for plans ML34-ML37Opens new window
    - 2016 Large Group HDHP Evidence of Coverage TemplateOpens new window



    - Sutter Health Plus First Quarter 2017 Small Group RatesOpens new window
    - Sutter Health Plus First Quarter 2017 Individual and Family Plan RatesOpens new window