Third Party Payer Complaint Form |
1. Please utilize this form to report problems with third party payers.
This form is only intended for use by dentists and dental office staff. The information provided on this form is for data collection and trending purposes only. No individual follow up is intended.
Please record one complaint occurrence per form. At the end of the form, you will be asked if you would like to submit information on additional complaints.
Please record one complaint occurrence per form. At the end of the form, you will be asked if you would like to submit information on additional complaints.