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Health Care Provider Complaint Form. This is a Massachusetts form and can be use in Workers Comp.
Tags: Health Care Provider Complaint Form, 134, Massachusetts Workers Comp,
Massachusetts General Law, Chapter15224713(3), requires the Health Care Services Board to receive and investigate compensation claim s, where the providers are alleged to have engaged in patterns of: (i) discrimination against compensation claimants; (ii) over - utilization of procedures; unnecessary surgery or other procedures; or (iv) other inappr opriate treatment of compensation recipients Where the Health Care Services Board finds a pattern of abuse, it shall refer its findings to the appropriate Board of Registration. Please check ( ) the appropriate box above to indicate the category t o which this complaint relates. TO FILE A COMPLAINT, PLEASE PROVIDE THE FOLLOWING INFORMATION: ABOUT THE PERSON FILING THIS FORM: YOUR NAME: ADDRESS: CITY: STATE: ZIP COD E: YOUR RELATIONSHIP TO THE COMPLAINANT: YOUR FIRM, COMPANY OR EMPLOYER: ABOUT THE HEALTH CARE PROVIDER: SPECIALTY (if known): ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE: ( ) THE DATE(S) OF THIS INCIDENT: Using the following space, summarize your complaint about this health care provider in 50 words or less . In addit ion , attach a detailed narrative of your complaint to this form describing the treatment(s), procedure(s), date(s), location(s), a nd other fact s relevant to the complaint. Was this an impartial examination ordered by the Department of Industrial Accidents? YES NO Was this a health care service performed by the treating health care provider, YES NO or a service performed by a provider chosen by an insurer or employer? YES NO Reproduce as Needed Revised 7/20 1 9 Page 1 of 2 The Commonwealth of Massachusetts Department of Industrial Accidents Lafayette City Center, 2 Avenue de Lafayette Boston, Massachusetts 02111 HEALTH CARE PROVIDER COMPLAINT FORM FORM # 134 Complaint # American LegalNet, Inc. www.FormsWorkFlow.com HCSB PROVIDER COMPLAINT FORM #134 Page 2 of 2 PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT THE COMPLAINANT : THIS COMPLAINT IS BEING FILED ON BEHALF OF AN (Ple a se Check One ): EMPLOYEE.... EMPLOYER .... INSURER.... OTHER .... THE COMP LAIN ANT S NAME: CITY: STATE: ZIP CODE: AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION: The following authorization for the release of medical information must b e signed by the injured employee. If this complaint is filed by an insurer or employer referencing several injured employees to demonstrate a questionable pattern of care or service by a single provider, a signed authorization for release of medical info r mation from each employee whose treatment is detailed in the complaint must be attached hereto. RELEASE OF MEDICAL INFORMATION o ard with all medical information, including but not limited to, medical records, test results, reports, and/or office notes, regarding an illness or injury for which you treated me during the period of to . I further authorize you to discuss with the Health Care Services Board any aspects of my illness or injury, or the treatment, diagnosis, or prognosis of my illness of injury. A photocopy of this authorization should be regarded as a valid r elease of the information requested. Date Signature of Employee/Patient - - Social Security No. (optional) Name of Employee/Patient (please print) Date o f Birth Address City/Town State Zip Code SEND THE COMPLETED COMPLAINT FORM, WITH ATTACHMENT(S) , AND SIGNED EMPLOYEE AUTHORIZATION(S) TO: DEPARTMENT OF INDUSTRIAL ACCIDENTS HEALTH CARE SERVICES BOARD LAFAYETTE CITY CENTER 2 AVENUE DE LAFAYETTE ATTN: Hella Dalt on A COPY OF THIS COMPLAINT AND ALL ATTACHMENTS WILL BE FORWARDED TO THE PROVIDER. Rep r oduce as Needed Revised 7 / 2019 American LegalNet, Inc. www.FormsWorkFlow.com