Dentists must obtain informed consent for every treatment you propose and perform on patients or from the patient's legal guardian or decision-maker. To obtain licensure verification, please complete form on the main page on the left said labeled "Verification of Licensure Request Form".I am provided with this refusal form and information so I may understand the recommended treatment and the consequences of refusing treatment. In most cases, the refusal to have radiographs will compromise treatment. The radiographs are needed to view existing and potential areas of concern. In this case study, a patient presents to her dentist with tooth decay but refuses xrays. You may need to refer to these documents while you are filling out the complaint form. Go online and find the ADA. They offer a form on their website specifically for filing a complaint. There are several reasons why an insurance company may refuse to pay a dental claim.