Dispute Resolution Form (Concentra Integrated Services)
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Dispute Resolution Form (Concentra Integrated Services) Form. This is a South Dakota form and can be use in Workers Compensation.
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Dispute Resolution Form
Date:
From: Name:
Address:
Telephone Number:
RE:
Claimant Name:
Date of Injury:
Claim Number:
Employer:
Description and Summary of Dispute:
Please attach any supporting documentation that should be considered.
Please submit to:
Concentra/Focus Health Care Management Inc.
Attn:
Denise
Warner
P.O.
Box
507
Mitchell, SD 57301
Telephone:
866-322-4689
Fax:
605-996-3778
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
Labor.
