Confidential Grievance Online Form

We are glad you are here.

Patient's Name: Date:

Subscriber's Name: Group Name: I don't know my group name.

Member Number: I don't know my member number.

Address:

City:

State: Zip Code:

Phone Number:

Dentist Name: Office Name:

Dentist Phone Number:

Provider Address:

Dentist City:

State: Zip Code:

Incident Details: Please state the date, parties involved and exactly what happened. Make sure to provide any information relevant to this issue (e.g. name of dentist involved, representative name(s), department(s) involved, and/or any other information).

List the names, addresses, and phone numbers of anyone who may have been a witness.

Statement of observation by any witness(s):.

Issue is with My Dentist

Issue is with My Dental Coverage.

English
IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For free help, please call right away at 1 866 756 4259. or TTY 888.645.1257 for the hearing and speech impaired.

Spanish
IMPORTANTE: Si Ingles es su Segundo idioma, usted podria obtener esta informacion en su propio idioma. Para ayuda gratuita, llame al 866-756-4259. Dental Health Services tiene una linea gratuita TTY 1-888-645-1257 para personas con necesidades de audicion y habla.

Independent Medical Review (IMR) through the California Department of Managed Health Care

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (1-800-637-6453) and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online. If you have questions or need assistance filing a grievance, you may contact Dental Health Services' Members Services at 503-281-1771. You may also file a complaint or seek assistance from the Oregon Insurance Division. Assistance is available:
By calling 503-948-77984 or the toll free message line at 888-877-4894;
By electronic mail at: [email protected];
By writing to the Oregon Division of Insurance, Consumer Advocacy Unit at:
P.O. Box 14480; Salem, OR 97309-0405; or Through the Internet at http://www.insurance.oregon.gov/consumer/consumer.html

Dental Health Services complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, disability, or sex.

Spanish
Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Dental Health Services, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-866-756-4259.

Vietnamese

Thông báo này có các thông tin quan trọng. Thông báo này có các thông tin quan trọng về đơn yêu cầu hay bảo hiểm của quý vị thông qua Dental Health Services. Có thể có những ngày quan trọng trong thông báo này. Quý vị có thể cần hành động chậm nhất vào một số thời hạn cuối cùng để duy trì bảo hiểm y tế của quý vị hoặc để được trợ giúp với các chi phí. Quý vị có quyền nhận thông tin này và được trợ giúp miễn phí bằng ngôn ngữ của quý vị. Gọi 1-866-756-4259

If you have questions or need assistance filing a grievance, you may contact Dental Health Services' Members Services at 800-637-6453. You may also file a complaint or seek assistance from the Washington State Office of Insurance Commissioner. Assistance is available:
By calling 800-562-6900 or;
By writing to the Washington State Office of Insurance Commissioner, Consumer Advocacy at:
P.O. Box 40255; Olympia, WA 98504-0255; or Through the Internet at www.insurance.wa.gov.

Dental Health Services complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, disability, or sex.

Chinese
如果您，或是您正在協助的對象，有關於[插入項目的名稱 Dental Health Services 方面的問題，您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話 [在此插入數字 1-866-756-4259.

Confidential Grievance Online Form

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