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.

Enter Today's Date

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* 1. Enter Today's Date

Today's Date
Enter Dentist's Name

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* 2. Enter Dentist's Name

Third Party Payer Name

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* 3. Third Party Payer Name

Is the Dentist Contracted with the Plan?

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* 4. Is the Dentist Contracted with the Plan?

If your complaint is about a specific claim(s), how was the claim filed?

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* 5. If your complaint is about a specific claim(s), how was the claim filed?

What type of complaint or problem applies to you? (check all that apply)

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* 6. What type of complaint or problem applies to you? (check all that apply)

Please give a brief description of the problem.

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* 7. Please give a brief description of the problem.

May the CSDA Contact you if we require additional information?

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* 8. May the CSDA Contact you if we require additional information?

Would you like to submit information regarding another complaint?

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* 9. Would you like to submit information regarding another complaint?

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