WRITTEN MEMBER GRIEVANCE FORM
MEMBER INFORMATION
Member last name
Member first name
Today’s date
Member street address
Member phone number
Employer or Group
City
State
ZIP code
Member identification number (see identification card)
Patient name
Relationship
DENTAL OFFICE/PROVIDER INFORMATION
I am authorizing LIBERTY Dental Plan to request my information, including chart records and x-rays, if applicable, from the following office:
Office number Dental office name Date of last visit
Dental office street address
Dental office phone number
City
State
ZIP Code
Name(s) of dental office staff involved (if known)
Description of Grievance
Describe your grievance in detail. Please provide the dates, names and treatment that are the subject of your grievance. Attach additional pages, if necessary.
