Complaint & Grievance Form

Please provide as much detail as possible, including any supporting documentation. For assistance in completing this form, or if you have any questions, please call: 888-632-3676.

Para ayuda a llenar esta forma, o si usted tiene cualquier pregunta, por favor llame: 888-632-3676

First Dental Health (the “Plan”), the parent company of New Dental Choice (NDC), will take the following steps to resolve a Complaint/ Grievance filed:

  • Upon receipt of the Complaint / Grievance, an investigation will commence with an initial call to the provider's office (within 48 business hours of receipt by New Dental Choice)
  • If not resolved within five (5) days, an Acknowledgement of Complaint letter will be sent via US First-Class Mail or Email
  • Once a satisfactory outcome has been reached and the Complaint /Grievance is considered resolved by all parties, a Resolution letter is sent to the member either by US First-Class Mail or Email within thirty (30) calendar days of the Acknowledgment of Complaint letter

Thank you for taking the time to express your opinions and concerns. Your feedback is important to us and is viewed as an important tool in providing a quality dental discount program. If you have any questions, contact us at 1-888-623-3676, Monday to Friday 8:00am to 5:00pm PST or by email at

The California Department of Managed Health Care is responsible for regulating discounted fee plans. If you need help with a grievance that has not been satisfactorily resolved by the Plan you may call the Department at (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing- and speech-impaired. The Department’s Internet Web site ( has complaint forms and instructions online.

Member Information

First Name  
Member Phone  
Membership ID  
Patient Name  
Date of Service  

Dentist Information

Dentist Name  

Complaint and Grievance Comment