Masshealth Member Dental Complaint Form - Masshealth Dental Program, Boston, Ma printable pdf download

Serving the MassHealth Program*

MassHealth Member Dental Complaint Form

PLEASE RETURN FORM TO:

MassHealth Dental Program

Attention: Intervention Services

P.O. Box 9708

Boston, MA 02114-9708

If you have any questions regarding this form or how to complete it, please call Intervention Services at 800-207-5019.

Name of person completing this form: __________________________________________

Relationship to Member: ____________________________________________________

Date Problem Occurred: ____________________

Member Information:

Member’s Name: _________________________________

MassHealth ID Number ___________________________

Social Security Number: _______________________________

Address: ___________________________________________

City:

State:

Zip Code:

Phone Number: ________________________________________

Provider Information:

Involved Provider’s Name: ________________________________

Address: ______________________________________________________________________________________

City:

State:

Zip Code:

Office Phone Number:__________________________

Please explain in your own words what occurred (attach additional pages, if necessary):

_______________________________________________________________________________________________

Please include a copy of any bills or other documents related to your complaint.

Signature: ____________________________________________ Date: _________________________

Print Name: __________________________________________________________________________

MassHealth will acknowledge receipt of the Complaint in writing within ten (10) business days of receiving the

Complaint. You will receive a resolution, in writing within thirty (30) days of the date MassHealth first received your

Complaint.

* DentaQuest, LLC is the subcontractor to Dental Service of Massachusetts, Inc.

Masshealth Member Dental Complaint Form - Masshealth Dental Program, Boston, Ma