Participant Procedures and Resources

Medical Release of Information 

Click here for Harbor Health’s medical release of information.

Elder Service Plan PACE Participant Rights 

Click here to download the Elder Service Plan PACE Participants Rights. 

Grievances and Appeals

Grievances and Complaints

At ESP we strive to provide you with excellent care and services. If you are not happy with the care or services you receive by ESP or one of our Contracted Providers, we encourage you or your representative, family member or caregiver to file a Grievance. You have the right to express complaints without discrimination or reprisal, and without fear of discrimination or reprisal.  

To file a Grievance, you can: 

  • Express your complaint to one of our employees or Contracted Providers in person or call us at (774) 470-6740 or if you need text telephone assistance, please use our TTY number, (617) 533-2404. 
  • You can write your complaint in a letter and: 
  • Give it to us in person 
  • Fax it to (617) 533-2401 
  • Mail it to the Quality & Compliance Department, 1135 Morton Street, Mattapan, MA 02126 

If you have questions about our process or would like an update of your grievance, you can call us (774) 470-6740.  

We will not retaliate against you for filing a complaint. If you have a concern regarding your rights as a patient or a breach of patient information, please contact our privacy officer: 

Felicia Talbot
617-533-2371 or TTY number — 617-533-2404
Email: [email protected]

Harbor Health Services also offers a compliance hotline where anonymous complaints can be filed. Our hotline is available 24-hours a day. Please call 1-833-310-0040.  

If you feel as though your concerns are not adequately resolved by a member of our staff, you may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by calling 1-877-696-6775. 

Participants also have the right to contact 1-800-Medicare for information and assistance, including to make a complaint related to the quality of care or the delivery of a service. 

Participants, their representatives, have the right to appeal any treatment decisions made by ESP or our Contracted Providers or if we decide not to cover or pay for an item or service including denying, reducing, or terminating an item or service. 

You can request an appeal by: 

  • Faxing a request to 617-533-2401 or 
  • Mailing a request to the Quality and Compliance Department at: 

1135 Morton Street
Mattapan, MA 02126

You can also contact us at (774) 470-6740 to ask questions about this process and/or request an update to a current appeal. 

You can request an expediated or fast appeal if you think your life, health, or ability to regain or maintain maximum function could be seriously jeopardized. The fast appeal is decided on within 72 hours. If you need a fast appeal after hours, call the Elder Service Plan/PACE Center. 

Appointing a Designated Representative 

To appoint a representative to act on your behalf for your claim, appeal, grievance or request you will need to fill out the following form:  

CMS Appointment of Representative Form (CMS Form-1696) 

If you click the link above, you will be leaving Harbor Health’s ESP website. 

Disenrollment in PACE 

Participants have the right to disenroll from ESP’s PACE program at any time without cause. The disenrollment will be effective on the first day of the month following the date we receive the participants’ notice of voluntarily disenrolling. 

Participant Responsibilities for Disenrolling

Here are the participant’s responsibilities for disenrolling: 

  1. Call (774) 470-6740 to inform Elder Service Plan (ESP) that you will be disenrolling.  
  2. Provide ESP with notification of who you will be transitioning your care to so we can make the appropriate referrals and send your medical records. 
  3. You must continue to receive your care and services from ESP and pay any premiums until your disenrollment date.  

You cannot disenroll from ESP’s PACE program at a Social Security Office. If you leave ESP’s PACE program and join another Medicare or Medicaid program, you may not get the same care or services you had with ESP. 

Harbor Health’s Patient Rights & Responsibilities 

Click the links below to download the Patient Rights & Responsibilities document in your preferred language.

Notice of Privacy Practices 

Click the links below to download the Notice of Privacy Practices document in your preferred language.

Non-Discrimination Policy 

Harbor Health Elder Service Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, ethnicity, national origin, religion, age, sex, mental or physical disability, sexual orientation or source of payment (For example, Medicare or Medicaid/MassHealth). The Harbor Health Elder Service Plan does not exclude or treat individuals differently. 

Procedure

If you think you have been discriminated against for any of these reasons, contact our Quality and Compliance Department to help you: 

By mail: 1135 Morton Street, Mattapan, MA 02126,

By phone: (774) 470-6740 or if you need text telephone assistance, please use our TTY number — (617) 533-2404

Fax: 617-533-2401

Email: [email protected]

If you have any questions, you can also contact the Office for Civil Rights: 

If you click the link above, you will be leaving Harbor Health’s ESP website. 

  • By mail:  

U.S. Department of Health and Human Services
200 Independence Avenue, SW Room 509F, HHH Building
Washington, D.C. 20201

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

If you click the link above, you will be leaving Harbor Health’s ESP website. 

Accessibility Resources 

Harbor Health Elder Service Plan provides free aid and services to people with disabilities to communicate effectively with us, such as: 

  • Qualified interpreters, including sign language 
  • Written information in other formats (large print, braille, audio, accessible electronic formats, other formats)  
  • Information written in other languages 

If you need these services, ask a member of our team. 

We also have a teletypewriter (TTY) telephone number available: (617) 533-2404. 

Resources 

If you click any of the links below, you will be leaving Harbor Health’s ESP website. 

Harbor Health’s Elder Service Plan (ESP) will be your sole provider for primary care and specialty care (other than emergency services). Care is provided directly by ESP or a provider we approve. ESP participants may be fully and personally liable for the costs of unauthorized or out-of-ESP program services.

This health center receives HHS funding and has federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals. H2218_Web_11-5-2025 Pending CMS review.