Patient Grievance Form

Please fill out this form as completely as possible. Your concerns are important to us. This information will help our investigation. We take every precaution to protect sensitive information such as social security numbers. For more information, see our Privacy Statement.

Patient and dentist information

Patient's Name

Patient's Date of Birth

Patient's Phone #

Primary Enrollee's Name

Enrollee's Social Security #

or ID#

Street Address

City

State

Zip

Dentist's Name

Dentist's Phone #
(optional)

Dentist's City

Nature of concern and additional information

When was treatment provided?

Was it completed?

Yes

Have you discussed your grievance with the dentist or his/her staff?

Yes

If an agreeable solution can be reached, would you return to the dentist who provided treatment?

Yes

Your e-mail address (optional)

Note: A copy of this grievance form may be forwarded to the dentist(s) who provided treatment.

If you prefer to mail or telephone your grievance, contact us at:

Customer Service
Delta Dental of California
P.O. Box 997330
Sacramento, CA 95899-7330

Toll-free number:
800-765-6003

The law requires the following be placed on all plan grievance forms:

You will receive written confirmation of your grievance within 5 days. You will receive a written decision on your request for review within 30 days unless more information is needed to resolve the matter.

If you have completed Delta Dental's grievance process or if you have been involved in Delta Dental's grievance process for 30 days, you may file a grievance with the California Department of Managed Health Care if Delta Dental has not satisfactorily resolved your grievance. You may immediately file a grievance with the Department in an emergency situation which is one involving severe pain and imminent and serious threat to your health.

The California Department of Managed Health Care is responsible for regulating health care service plans. The department has a toll-free telephone number (1-888-HMO-2219) to receive grievances regarding health plans. The hearing and speech impaired may use the California Relay Service's toll-free telephone numbers (1-800-735-2929 (TTY) or 1-888-877-5378 (TTY) ) to contact the department. The department's Internet website (http://www.hmohelp.ca.gov) has grievance forms and instructions online. If you have a grievance against your health plan, you should first telephone your plan at (1-888-335-8227) and use the plan's grievance process before contacting the department. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. The plan's grievance process and the department's grievance review process are in addition to any other dispute resolution procedures that may be available to you, and your failure to use these processes does not preclude your use of any other remedy provided by law.