COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : DISPUTEPlaintiff(s) RESOLUTION JUDICIAL SUBPOENA For -against: Case Management Plans : : The Dispute Resolution process is provided to ensure the prompt response and Defendant(s) : . . . . . satisfactory .resolution .of. all .disputed .issues.. . . . . . . . . . . .......... ........ . .. ....... ..... The following paragraph is abstracted from Article 47:03: CASE MANAGEMENT PLANS YORK THE PEOPLE OF THE STATE OF NEW FOR WORKERS’ COMPENSATION: Article 47:03:04:10. Dispute Resolution. Any person or entity aggrieved by the action TO of a certified case management plan must exhaust the dispute resolution procedure of the plan prior to filing a petition or otherwise seeking relief from the department on an issue related to case management. If the aggrieved party has exhausted the dispute resolution procedure of the case management plan or the plan has failed to resolve a dispute within GREETINGS: 30 calendar days after the dispute was submitted to the plan, the party may petition the department for a hearing on the matter in dispute pursuant to SDCL chapter 1-26. The WE for a hearing must be all business and excuses being laid aside, you and each of you petitionCOMMAND YOU, thatmailed within 30 calendar days after written notice of the attend before , the Honorable at the Court final decision of the case management plan is mailed to the aggrieved party. located at County of in room , on the , 20 , o'clock in noon, and An acknowledgement of day of of the dispute willat provided to thethe receipt be aggrieved party at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the from the case management plan within 2 business days of the dispute being filed. The case management plan will provide a written notice of their resolution to the disputed Your failure to comply with within 30 calendar days as a contempt of court and will issue(s) to the aggrieved partythis subpoena is punishableof receiving the complaint. make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result The form on the comply. page may be used when filing a dispute. of your failure to following Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : Dispute Resolution Form : : Date: ____________________ Defendant(s) : ...................................................... From: Name: _______________________ THE PEOPLE OF THE STATE OF NEW YORK Address: TO _______________________ _______________________ Telephone Number: _______________________ GREETINGS: WE COMMAND YOU, RE: Claimant Name: that all business and excuses being laid aside, you and each of you attend before ________________________ , the Honorable at the Court located at County of Date of Injury: _________________________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to Number: give evidence as a witness in this action on the part of the testify and Claim _________________________ Employer: _________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result Description to comply. of your failure and Summary of Dispute: Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Please attach any supporting documentation that should be considered. Please submit to: The Administrator of the Certified Case Management Plan (Chiropractic Associates, Ltd. of South Dakota, 323 22nd Avenue, Brookings, SD 57006) Office and P.O. Address It is the goal of the case management plan to resolve this issue within 30 days of receipt of this form. At that time, should resolution not be achieved, or there continues to be dissatisfaction of the results, an appeal may be made to the South Dakota Department of Telephone No.: Labor. Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com