What is the Grievance, Standard Appeal, and Expedited Appeal Form for?

Clients use it to report dissatisfaction with a matter or request review of an action involving services. The form lets the filer select a grievance, standard appeal, or expedited appeal.

Who can file a grievance or appeal?

The form is for clients of Alpine County Behavioral Health Services. It says another person may call or write on a client’s behalf for a grievance, and a client may authorize a representative for an appeal.

Do I need a notary for the Grievance, Standard Appeal, and Expedited Appeal Form?

No. This form is signed and dated without a notary, and it does not identify any attachment or related step that must be notarized or sworn.

How do I submit the Grievance, Standard Appeal, and Expedited Appeal Form?

Return the completed form to Alpine County Behavioral Health Services, 40 Diamond Valley Rd., Markleeville, CA 96120, as directed on the form.

Alpine County, CA · Alpine County

No notary required

Grievance, Standard Appeal, and Expedited Appeal Form

Alpine County Behavioral Health Services clients use this form to submit a written grievance or request a standard or expedited appeal.

At a glance

Issued by: City of Alpine County · Alpine County, Alpine County, California
Notarization: Not required: file this form without a notary.
Official source: alpinecountyca.gov
Blank form: Download the PDF
Catalogued: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

Clients of Alpine County Behavioral Health Services can use this form to report dissatisfaction or request review of an action, such as a denied, reduced, or delayed service. Select a grievance or appeal type and provide the filer’s contact details, request date, reason, and signature. The form also explains the grievance and appeal processes, including when an expedited appeal may be appropriate.

Who needs it

Clients of Alpine County Behavioral Health Services who want to submit a written grievance or appeal an action can use this form.

How to submit it

Return the completed form to Alpine County Behavioral Health Services at 40 Diamond Valley Rd., Markleeville, CA 96120, as directed on the form.

About notarization

This form is signed and dated without a notary; it does not identify any attachment or related step that must be notarized or sworn.

How to submit this form

1
Download the Form
Download the Grievance, Standard Appeal, and Expedited Appeal Form.
2
Complete the Form
Select the request type, provide the filer’s contact information and request date, explain the reason, and sign and date the form.
3
Gather Attachments
The form does not list required attachments. It explains that supporting evidence may be presented during an appeal.
4
Submit to the County
Return the completed form to Alpine County Behavioral Health Services, 40 Diamond Valley Rd., Markleeville, CA 96120.

Frequently asked questions

What is the Grievance, Standard Appeal, and Expedited Appeal Form for?: Clients use it to report dissatisfaction with a matter or request review of an action involving services. The form lets the filer select a grievance, standard appeal, or expedited appeal.
Who can file a grievance or appeal?: The form is for clients of Alpine County Behavioral Health Services. It says another person may call or write on a client’s behalf for a grievance, and a client may authorize a representative for an appeal.
Do I need a notary for the Grievance, Standard Appeal, and Expedited Appeal Form?: No. This form is signed and dated without a notary, and it does not identify any attachment or related step that must be notarized or sworn.
How do I submit the Grievance, Standard Appeal, and Expedited Appeal Form?: Return the completed form to Alpine County Behavioral Health Services, 40 Diamond Valley Rd., Markleeville, CA 96120, as directed on the form.

Need something notarized?

This Grievance, Standard Appeal, and Expedited Appeal Form doesn’t need a notary, but if you have another Alpine County form that does, a commissioned online notary can help.