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Billing or Account Inquiry Form

For inquiries involving a WDS contracted provider other than a Western Dental Center, please call Western Dental's Member Services at (800) 992-3366 between 8:30 am and 5:00 pm (Pacific time).

* Indicates Required Fields

Member Information
First Name*: Last Name*:
Address*: City and State*:
Zip Code*:
Phone Number (Day)*:
Phone Number (Night)*: Email Address*:
(Format: ###-###-####)

Account Information
Office Name*:
Dentist Name(s)*:
Address*:
City and State*:
Zip Code*:

Phone Number*:

Responsible Party
First Name: Last Name:
Address: City And State:
Zip code: Phone Number (Day):
Phone Number(Night): Email Address:

Insurance Information
  Insurance 1 Insurance 2
Name of Insurance:
Address:
City And State:
Zip Code:

Dental Plan #:
Group #:
Member Number:
Subscriber Number:

Have you discussed your inquiry with the office manager? Yes |No

This form is to be used for inquiries involving your Western Dental account. If you have other questions or concerns, you may contact Western Dental's Member Services at (800) 992-3366 or complete a Member Incident Form

"The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your Health Plan, you should first telephone your Health Plan at 1-800-992-3366 and use your Health Plan's grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your Health Plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a Health Plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department's Internet Web site http:/www.hmohelp.ca.gov has complaint forms, IMR application forms, and instructions online."


Call now to schedule an appointment at your nearest office:
1-800-57-WESTERN or 1-800-579-3783