Request for Peer Review

Upon receipt of this completed form, a mediator will be assigned who will contact you to discuss your request and attempt to resolve your problem.

Patient Information  
First Name
Last Name
Phone Number xxx-yyy-zzzz  Day      Night
Email
Mailing Address
City
State
Zip
   
Dentist Information  
Dentists Name
Address
City
State KS*  (Only dentists practicing in Kansas are eligible for peer review)
Zip
Phone
   
Have you contacted the dentist office about your concern? Yes No
Date of last appointment
xx/yy/zz
Date of treatment in dispute
xx/yy/zz
 
Please describe the problem(s) specific to the dental treatment received:
 
From my point of view, here is how I think the problem should be resolved.  While a refund of the charges you have paid is on of the options that may be recommended by the mediator, a request for a refund should not be made at this time.  If a refund is an option you wish to pursue, please explain why a refund should be given.
 
In order that a complete review be performed, I authorize the release to the Kansas Dental Association Council on Peer Review of any dental records or information by anyone who has examined me previously.  I further give my permission for the Committee to perform a clinical examination if necessary.
Electronic Signature - Please type your full name in the box below, indicating your acceptance of the release of records for this purpose.
 
Digital Signature
Date

Thank you for addressing your concerns to the Kansas Dental Association.