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City, state and zip code: Web the ada dental claim form provides a common format for reporting dental services to a patient's dental benefit plan. State of michigan ada complaint form. If you have experienced discrimination because of your disability, you can file a complaint with the government. Please remember to save and/or print your completed appeal form before using.
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Use this chart to find the right agency and the process for filing your complaint. If you have experienced discrimination because of your disability, you can file a complaint with the government. Please fill out this form completely, in black ink or type. To file a complaint using by mail, send your complaint form to the following address:
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