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For Eyes Vision Plan is providing this Online Grievance Form to you to ensure member complaints are heard and responded to in a timely manner. For Eyes Vision Plan has established a system to give your concerns prompt attention. Alternatively, you may submit an online Grievance in Chinese and Spanish.

You may also file your grievance over the telephone by calling For Eyes Vision plan at:


You can also submit your complaint by e-mail to grievance or mail your completed form to:

For Eyes Vision Plan, Inc.
2112 Shattuck Avenue
Berkeley, CA 94704

You can access the online form with the link above or click on the link for the form in the appropriate language:

English Grievance Form (PDF)

中國申訴表 (PDF)

Formulario de Quejas en Español (PDF)

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-800-454-3937 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatment that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing- and speech-impaired. The department’s Internet Web site has complaint forms, IMR applications forms, and instructions online.