Fraud and Abuse Form

Fraud Complaint Form

If you have concerns regarding misleading or incorrect information on your Explanation of Benefits, dental treatment received, or the billing practices of a dentist you have received treatment from while covered by TruAssure, please use this form to file your complaint. You may also report your concerns by calling us at 855-891-1153. NOTE: If you choose to submit your complaint online, please be advised that communications submitted through the Internet are not considered secure. Although it is unlikely, there is a possibility that information you include in electronic communications (online and email) can be intercepted and read by other parties besides the person to whom it is addressed. You always have the option of submitting a complaint by mail or fax. Please do not include any sensitive protected health information, such as your Social Security number or birth date in electronic communications you send to us. *Required

Your Information

Your name*

Your name* is mandatory

Patient name*

Patient name* is mandatory

Member ID

Member ID is mandatory

Email*

Email* is mandatory

Phone*

Phone* is mandatory

Phone number should be numbers only, without dashes. For example: 5405555555.

Dental Provider Information

Dentist's name*

Dentist's name* is mandatory

City*

City* is mandatory

State*

Please select at least one of the items

Zip code*

Zip code* is mandatory

Complaint(s)

What is your complaint?*

This field is mandatory