For more than 20 years, Bank of America Practice Solutions has served the needs of dentists by offering financial products and services to the dental community

PATIENT REQUEST FOR MEDIATION

Upon receipt of this completed form, a mediator will be assigned and will contact you to discuss your request and help resolve this issue. While a refund of the charges you have paid is one of the options that may be recommended by the mediator, a request for a refund should not be made in writing or on this form.

*Required field(s) are indicated by an .**
* Today's Date	,
* County
* Your First Name
* Your Last Name
* Your Area Code	Please enter numbers only.
* Your Phone Number	Please enter numbers only.
* Your Address
Suite or Apt Number
* City
* State
* Zip
* Your Email Address
* Dentist's Full Name
* Dentist's Area Code	Please enter numbers only.
* Dentist's Phone	Please enter numbers only.
* Dentist's Address
* Dentist's City
* Dentist's State
* Dentist's Zip Code	Please enter numbers only.
* Dentist's County
* Date of Last Appointment	,
* Your Day Phone Number (include area code)	Please enter numbers only.
Best Day Time to Call
* Your Night Phone Number (include area code)	Please enter numbers only.
Best Night Time to Call
* Briefly describe your dental problem
* Please type your name here