Complaint Resolution
Patient Information
Request for Peer Review Submitted by:
*
Patient
Parent / Guardian
Dentist
Insurance Company
Patient Name:
*
Parent / Guardian Name (if patient is a minor)
Address
*
Email:
*
example@example.com
Phone Number:
*
-
Area Code
Phone Number
Best Way to Reach You:
*
Email
Phone
Mail
Dispute Information
Reason for Submission (e.g. crown, dentures, filling, etc.):
*
Has an attempt been made to resolve the situation with the dental office or through an insurance company?
*
Yes
No
First and Last Name of Dentist:
*
Address Where Treatment Was Provided:
*
Did any dental insurance company (or Medicaid) pay toward the treatment in question?
*
Yes
No
Have you sued your dentist, or has your dentist sued you, in relation to this complaint?
*
Yes
No
If you sued your dentist, or your dentist has sued you in relation to your complaint, please explain below:
Submit
Should be Empty: