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Sample Complaint Resolution Protocol & Log for Medicare DME Suppliers

Sample of a complaint resolution protocol & complaint log for dental practices enrolled as a Medicare DME supplier for sleep apnea oral appliances

DME Supplier, Inc.

17 Main Street

Anywhere, SC 29999




The patient has the right to freely voice grievances and recommend changes in care or services without fear of reprisal or unreasonable interruption of services. Service, equipment, and billing complaints will be communicated to management and upper management. These complaints will be documented in the Medicare Beneficiaries Complaint Log, and completed forms will include the patient’s name, address, telephone number, and health insurance claim number, a summary of the complaint, the date it was received, the name of the person receiving the complaint, and a summary of actions taken to resolve the complaint.

All complaints will be handled in a professional manner. All logged complaints will be investigated, acted upon, and responded to in writing or by telephone by a manager within a reasonable amount of time after the receipt of the complaint. If there is no satisfactory resolution of the complaint, the next level of management will be notified progressively and up to the president or owner of the company.

The patient will be informed of this complaint resolution protocol at the time of set-up of service.




Date of receipt of complaint: _________________________

Patient’s name: _____________________________________________________________

Patient’s address: _____________________________

State ______________    Zip code ____________

Patient’s telephone number: _____________________________________

Patient’s Medicare or Health Insurance Claim Number: _____________________________

Description of complaint: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Action taken to resolve the complaint: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature of representative   __________________________________    

Date ______________________