IUSD Patient Concern Form

Indiana University School of Dentistry Patient Advocacy Request

The Indiana University School of Dentistry is committed to patient centered care. IUSD defines Patient Centered Care as dental care that establishes a partnership among practitioners, patients and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care. If you feel that you need assistance addressing issues or concerns at IUSD, please complete this form to request the assistance of the IUSD Patient Advocates.

Patient Name

Patient Date of Birth

Patient Address

Phone Number

Patient Care/Treatment

This concern is regarding my patient care. (* required)
Did you discuss this concern with a member of your dental care team? (* required)
This concern is regarding my billing (* required)
This concern is regarding treatment or care provided to me by (* required)
Patient Treatment or Care Select any or all the factors that relate to your patient concern.

Select any or all the factors that relate to your patient concern.

Please indicate your fill-in choice for: Patient Treatment or Care
IUSD Personnel Select any or all the factors that relate to your patient concern.

Select any or all the factors that relate to your patient concern.

Please indicate your fill-in choice for: IUSD Personnel
Organizational Factors Select any or all the factors that relate to your patient concern.

Select any or all the factors that relate to your patient concern.

Please indicate your fill-in choice for: Organizational Factors
Clinic Location

Details regarding your patient concern.

Please provide a brief statement of those individuals involved in your patient concern,

Please provide dates involved in your patient concern.

Please provide a brief statement as to where this issue occurred. Ex: Graduate Program Clinic, Parking lot, Dental Student Clinics

Please provide details as to what happened or what your concerns are so that the IUSD Patient Advocate may begin to look into your concern.

Please provide any potential next steps or resolutions that you are requesting or have been requesting.

Authorization to Review

By submitting this form, I am agreeing to authorize the IUSD Patient Advocate and IUSD Personnel to review the above concern and advocate on my behalf. I understand the IUSD Patient Advocate and IUSD Personnel will review my dental record and/or discuss my case. I understand that it may take up to five (5) business days for a response from the IUSD Patient Advocate and that submitting multiple forms may delay responses to the reported concern.

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