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Get H: HOME FORMS MSBDE Forms-complaint Checklist For ...

L name and office address of the dental practitioner; full name of the person filing the complaint ("the complainant"); mailing address, home telephone number, and office telephone number of the complainant; and full names and addresses of any and all witnesses to the events surrounding the complaint. The complainant should fully complete the attached Authorization to Release Dental Information and include this form with the initial mailing of any complaint. The complainant should provide a tho.

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