BEUDAMED
    FDA Adverse Event Injury Summary report: N

    *

    MDR report key: 508930 · Received January 25, 2004

    Report

    Report Number
    MW1030934
    Event Type
    Injury
    Date Received
    January 25, 2004
    Date of Event
    October 22, 2003
    Report Date
    January 25, 2004
    Manufacturer
    UNK
    Product Code
    DYJ
    Adverse Event
    Yes
    Report Source
    Voluntary report
    Reporter Location
    IL, US
    Reporter Occupation
    PATIENT

    Narratives

    Description of Event or Problem · 1

    ORTHODONTIST FIT PT FOR AN UPPER & LOWER RETAINER FOR WHICH THEY DEMANDED PAYMENT UPFRONT BEFORE THE ITEMS WERE REC'D AT 258.00 PER RETAINER, TOTAL 516.00. ON PT'S VISIT TO PICK THEM UP THE BOTTOM RETAINER FIT BUT HE HAD INCORRECTLY ORDERED THE WRONG TYPE OF UPPER RETAINER, NOT TO MENTION IT DID NOT FIT. PT'S INSURANCE CO STATED THAT DR BILLED THEM 258.OO PER RETAINER, THAT THE CONTRACT RATE THAT HE LEGALLY AGREED TO CHARGE IS 177.00 PER RETAINER & DR OWES PT A DIFFERENCE OF THE CONTRACT RATE OF 81.00 PER RETAINER, TOTAL 162.00 FOR OVERBILLING. DR FIT PT AGAIN FOR THE UPPER & RESCHEDULED PT. HE REFUSED TO GIVE PT THEIR RETAINER OR REFUND THEIR MONEY AS PT HAS DISAGREED WITH HIS ATTEMPT TO KEEP MONEY WHICH DOES NOT BELONG TO HIM.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 * ORTHODONTIC RETAINER DYJ UNK * *

    Patients

    Seq Age Sex Outcome Treatment
    1 44 YR Other