Upham’s Elder Service Plan maintains its own Grievance Reporting Protocol which allows a participant of UESP to express dissatisfaction (including, but not limited to: dissatisfaction toward the treatment, service, lack of service, or respect for property or self that he or she feels entitled to; feels that their privacy has been violated; or feels that they have been discriminated against).

All grievances/complaints filed by a participant (or a caregiver(s) or family member(s) of a participants) are investigated in a prompt, equitable and thorough manner; and, the person filing the grievance/complaint will be informed of the resolution.

To File for Yourself

Please fill out a the GRIEVANCE FORM and return to by mail:
Upham’s Elder Service Plan
c/o Program Director
1140 Dorchester Avenue
Dorchester, MA 02125

By Phone:  Please call the program director at 617-288-0970.
By Fax:  Please fax the grievance form to: 617-474-0757

Our goal is to resolve the grievance to the satisfaction of all parties, and the Team will strive toward this end. We will give or send you a copy of the completed Grievance Form. Your Social Worker will verbally notify you of the resolution of the grievance within 30 days of filing your grievance. The Social Worker will discuss the results of the investigation including the steps taken to address the issues reported in your grievance.

If your grievance is of an urgent nature, the Clinical Director will become involved. The CEO of Upham’s Corner Health Center will review and respond to you within 30 days if the grievance is not able to be resolved. All grievances are sent to the CEO and Board of Directors of Upham’s Corner Health Committee, Inc.  You will continue to receive all your services during the grievance process. Your privacy during the grievance process will be protected.

To Appoint a Representative

Do you need someone to file a complaint or appeal for you? You will need to complete a form that will allow you to name someone to make decisions for you. This person is often a relative, friend, lawyer or doctor.

If you want to let someone represent you in a Medicare appeal or grievance, you must complete THIS FORM.

Make sure you have your Medicare number. Print or type your number and your name on the top of the form.

Appoint at least one person to act on your behalf. You can name more than one. If you do, you may want to complete a form for each of them.

You can appoint a spouse, family member, friend, lawyer or caregiver. You must name individual people. You can’t name a law firm, legal aid group or organization to represent you. It has to be a person.

Each person you appoint needs to complete the Acceptance of Appointment section. They provide their names and state where they accept the appointment.

The person or people you name should fill out the Waiver of Fee for Representation part of the form if he or she won’t charge you for acting on your behalf.

Voluntary Disenrollment

You may disenroll from UESP at any time.  If you wish to cancel your benefits by disenrolling, you should discuss this with the social worker at the PACE Center. You will need to sign a Disenrollment Form indicating that you will no longer be entitled to services through UESP.

The effective date of your disenrollment will be the first day of the month following UESP’s receipt of your disenrollment form. Your social worker will assist you with returning to the conventional health care system upon the termination date of your UESP benefits. You must continue to receive care through USEP after your request is received until your disenrollment effective date (end of month).

Last updated on February 11th, 2019 at 08:41 pm