Patient Grievance Form - Newport Dental

Please fill out the form below to file a patient grievance with a Newport Dental office.

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Date:

Office, Dentist:

First Name:

Last Name:

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Newport Dental's Grievance Process is a comprehensive resolution program to help solve any problems or complaints that you may have about your dental work or the Newport Dental Plan. This program not only provides assistance with resolving your complaints, but has an appeal process whereby the Quality Assurance Committee will review your grievances.

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 (800) 497-6453 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 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 website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.

IMPORTANT: You can get an interpreter at no cost to talk to your dentist or dental plan. To get an interpreter, first call your health plan’s phone number at 1-800-49SMILE (1-800-497-6453). Someone who speaks your language can help you. If you need more help, call the HMO Help Center at 1-888-466-2219.

IMPORTANTE: Puede obtener la ayuda de un interprete sin costo alguno para hablar con su dentista o con su plan de dental. Para obtener la ayuda de un interprete, primero llame al número de teléfono de su plan de salud al 1-800-49SMILE (1-800-497-6453). Alguien que habla español puede ayudarle. Si necesita ayuda adicional, llame al Centro de ayuda de HMO al 1-888-466-2219.