PESC Administrators

This form will give the PESC Administrators Peer Review Committee important background information on your case. Briefly describe your problem (be specific and include everything you can remember about dates, places, names, etc.).
If you need more space, use the hardcopy and mail or Fax it. (Download Acrobat Reader to view and print)

PATIENT INFORMATION

Date:

Patient's Name:

Address:
City: State: Zip:
Work Phone: Home Phone:

(if patient is less than 18 years old)

Parent/guardian Name :
Parent/guardian Address:
Parent/guardian City: State: Zip:
Parent/guardian Work Phone: Home Phone:

DENTIST INFORMATION

Dentist's Name:

Address:
City: State: Zip:
Work phone:

Date treatment started:
Date treatment completed:
Date last seen by this dentist:
Date you first felt there was a problem:

Do you know if this dentist is a specialist?

No Yes - indicate specialty:

Have you tried to settle this matter with the dentist?

No Yes - on which dates:

Did the dentist respond?

No Yes - what action did the dentist take?:

Have you been examined or treated by another dentist (s) for this problem?

No Yes - give name, address and phone:

Second dentist's name:
Second dentist's address:
Second dentist's phone:

Have you asked for help from any person, organization or agency?

No Yes - give names, dates, and actions being taken:

Are you aware of any litigation concerning this complaint including small claims court, notice of intent to sue, or if a malpractice suit has been filed?

No Yes - indicate type of action:

Do you have dental insurance now?

No Yes -

Name of person insured:
Insured's Social Security #:
Group I.D. #:
Insured's employer:
Name of insurance company:
Insurance company address:

Did your dental insurance pay any portion of this treatment?

No Yes - indicate amount: $

Has the insurance company been notified of this matter?

No Yes

How did you become aware of PESC Administrator's Peer Review Process?

What do you suggest as a fair solution to your problem?

By submitting this form below, I acknowledge that PESC Administrator’s peer review process handles only matters relating to appropriateness and/or quality of dental care. Problems about prices charged for dental treatment, reimbursement for lost time from work, or compensation for pain suffered is not and shall not be covered by PESC Administrator's peer review process:

Your Name:

(you must be the patient or the parent or guardian of the patient)

555 W. Shaw Ave., Suite C-1
Fresno, CA 93704

(866) 777-1320
(559) 256-1320
559.256.1321 fax