ENROLLEE GRIEVANCE SUMMARY FORM

DELTA DENTAL PREMIER ^® AND DELTA DENTAL PPO^SM ENROLLEE GRIEVANCE SUMMARY FORM

Please carefully review the summary of information below for accuracy before submitting your grievance form:

Enrollee and Patient Information
Enrollee First Name
Enrollee Last Name
Enrollee ID
Enrollee Date of Birth	/ / (mm/dd/yyyy)
Patient First Name
Patient Last Name
Patient Date of Birth	/ / (mm/dd/yyyy)
Patient Phone Number	( ) -
Street Address
City
State
ZIP Code	-

Nature of Grievance
Please include dates and names of persons involved.


Is this complaint about a dental provider? Yes No
Dental Provider Name
Dental Provider Phone Number	( ) -
Dental Provider City

Additional Information
When was treatment provided?	/ / (mm/dd/yyyy)
Was it completed?	Yes No
Have you discussed your grievance with the dental provider or his/her staff? Yes No
If an agreeable solution can be reached, would you return to the treating dental provider? Yes No
E-mail address

If the information displayed above is not accurate, please correct it now. Then, complete the grievance form by clicking the Submit button, or cancel this action by clicking the Cancel button. You may print this form using the print button in your browser.