Insurance Complaints

Third-Party Payer Complaints

Are you experiencing problems with third-party payers? You may complete the Insurance Complaint Form below to provide basic information regarding payer issues and complaints. An MDA team member will then contact you for further assistance, and will forward your complaint to the ADA, because they keep a close watch on carrier trends and problems.

Member Name

ADA Number

Office Insurance Staff Name

Please provide this contact if you wish for the MDA to speak with a specific person in your office regarding this complaint.

Office Phone

Office Email

Insurance Company Complaint Against

Description of Insurance Complaint

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Insurance Complaints

Third-Party Payer Complaints

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