GRIEVANCES/COMPLAINTS FORM Complaints against Bonnie Be Bodywork, LLC or the services that Bonnie Eason and independent contractors provide are formally considered grievances. This is broadly understood as any wrong that Bonnie Be Bodywork, LLC or its independent contractors is perceived as doing during, before or after sessions with the person receiving services, family members or anyone else involved in their care. If at any time the person receiving services, legal guardian of the person receiving services or authorized representative feels they would like to submit a grievance against Bonnie Be Bodywork, LLC or its independent contractors they are encouraged to do so, and this will not prejudice future provision of appropriate services. No individual shall be coerced, intimidated, threatened or retaliated against because the individual has exercised their right to file a grievance or participated in the grievance process. Grievances may be submitted directly to and through Bonnie Be Bodywork, LLC, by contacting the owner, Bonnie Eason. If additional support persons would be preferred, the case manager working with the person associated with the Community Centered Board can be recruited as a support person or mediator in the case the person submitting the grievance feels they would like a mediator. The Department of Regulatory Agencies also provides a form to file a complaint. * I have read and understand the above Grievances can be submitted by: Contacting Bonnie Eason directly [(Bonnieeason2@gmail.com, (970) 462-8104], Contacting the Community Centered Board’s allocated case manager working with the person receiving services, Filing a complaint against Bonnie Eason through the Department of Regulatory Agencies: https://apps.colorado.gov/dora/licensing/Activities/Complaint.aspx Upon submission of a grievance, Bonnie will make herself available as will the independent contractor if requested by the family to be involved, by phone or in person per the preference of the person submitting the grievance, to come together and find a mutually acceptable solution. The resolution of the grievance will be reached within 2 weeks of Bonnie Eason being notified but can be extended if the person submitting the grievance does not feel that a mutually acceptable solution has been reached. Services may continue during this time unless the person receiving services, legal guardian or authorized representative prefers that they are halted. Persons receiving services, the legal guardian of persons receiving services or authorized representative shall receive information about the grievance process prior to receiving services and upon any changes to the procedure. Does this show up? I have read and understand the above DISPUTE RESOLUTION: Disputes against the decisions of Bonnie Be Bodywork, LLC can be made at any time. The submission of a dispute shall not prejudice future provision of appropriate services. No individual shall be coerced, intimidated, threatened or retaliated against because the individual has exercised their right to participate in the dispute resolution process. at least 15 days written notification, provided in person or by first class mail, will be allowed for: The person receiving services is no longer eligible for services or supports, Services in the Individualized Plan are to be modified, reduced or denied, Services or supports are to be terminated, The applicant is not eligible for services or supports. In emergency situations, determined by Bonnie Be Bodywork, LLC, the person receiving services or their parent/legal guardian/representative, will result in immediate or less than 15 days’ notice termination of services. For all other cases, services will not be terminated during the dispute resolution process but will continue at the same location with the same frequency and duration. The opportunity for resolution of any dispute begins with an informal negotiation process, scheduled as a meeting of Bonnie Be Bodywork, LLC and the persons to receive therapy or their representative within fifteen days of receipt of the dispute. Mediation could be considered as one means to informal negotiation if both parties voluntarily agree to this process. If this process is waived or does not resolve, the following process may be initiated: Formal Negotiation - an opportunity to present information and evidence to an impartial decision maker. This will likely be CCB associated with the person receiving services, Notification of the meeting at least 10 days prior to the meeting unless waived by the person receiving services or their parent/legal guardian/representative, Representation by council, authorized representative or another individual if the person receiving services or parent/legal guardian/representative desires, The opportunity to respond to questions, Recording of the proceeding by electronic device or reporter, Written decision within 15 days of the meeting, Notification that if the dispute is not resolved, the person receiving services or parent/legal guardian/representative may request the following: Review by the Department of Health Care Policy and Financing, The request to review the outcome of the dispute resolution process shall be submitted to the Department within 15 days from which the decision was postmarked. The Department shall render a decision within 10 working days of the submission of all relevant information. The decision of the Department shall constitute final action on the dispute. * I have read and understand the above I understand that my typed name serves as a legally binding signature Yes Typed Signature * Thank you!