Patient Mediation Request

Filing a Patient Mediation Request

The North Carolina Dental Society's (NCDS) Patient Mediation process is designed to address complaints regarding the quality or appropriateness of treatment. NCDS Mediation involves impartial volunteer dentists who review information submitted by the patient, engage in discussions about case details, and then consult with the treating dentist to seek resolution. This process typically results in a satisfactory outcome for both parties.

Note: NCDS Patient Mediation only applies to cases involving member dentists and excludes those concerning billing, insurance, service costs, fee collection, office procedures, or unprofessional conduct by dental staff or practitioners.

If your dentist is not a member, we will contact you within seven business days to let you know we will not be able to proceed with patient mediation. However, we will send you additional resources to help you.

If the Patient Mediation process does not resolve the issue, patients have the option to file a complaint with the North Carolina Board of Dental Examiners, which provides a more formal and binding complaint system.

Contact Information:

North Carolina State Board of Dental Examiners
2000 Perimeter Park Dr., Suite 160
Morrisville, NC 27560
Telephone: (919) 678-8223
Website: www.ncdentalboard.org
Email: info@ncdentalboard.org

For cases not covered by NCDS Patient Mediation—such as those involving billing, insurance, service costs, fee collection, office procedures, or unprofessional conduct by dental staff or practitioners—patients have the option to the NC Attorney General’s Office Health Consumer Complaint division.

North Carolina Attorney General's Office
Health Consumer Complaint Division
9001 Mail Service Center
Raleigh, NC 27699-9001
Telephone: (919) 716-6400
Consumer Complaint Line: (877)-566-7226
Website: www.ncdoj.gov

Note: NCDS Patient Mediation only applies to cases involving member dentists and excludes those concerning billing, insurance, service costs, fee collection, office procedures, or unprofessional conduct by dental staff or practitioners.

Patient Information

Date

mm/dd/year

County

Name

Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Dentist Information *See above for restrictions on when patient mediation applies.

Treating Dentist's Name

Phone Number

Address

City

State

Zip Code

County

Date of Last Appointment

Please describe the problem(s) specific to the dental treatment received.

How have you tried to resolve the problem(s) with the dentist?

What outcome do you hope to see from the Patient Mediation process?

Single Document Upload

Do you have additional information you wish to provide?

Please give a phone number and the best time of day when the Mediator will be able to contact you.

Day Phone

Time

Night Phone

Time

In order that a complete review may be performed, I authorize the release to the Patient Mediator of any dental records or information by anyone who has examined me previously. I further give my permission for the Patient Mediator to perform a clinical examination if necessary. I understand that a copy of this form may be shared with the dentist in question.

Signature

Type your full name.

Patient Mediation Request

Patient Information

Dentist Information *See above for restrictions on when patient mediation applies.

Please give a phone number and the best time of day when the Mediator will be able to contact you.

General Information

Sections

Resources