GENEX Care for South Dakota 2500 W. 49th Street # 206 Sioux Falls, SD 57105 Dispute Resolution Form Provide all information requested below and describe your dispute in detail on the space provided below. Include dates, names, and the specific resolutions which you feel will remedy the situation. 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: GENEX Care for South Dakota 2500 W. 49th Street Suite #206 Sioux Falls, SD 57105 Phone: 1-877-858-1886 Fax 605-334-5639 It is the goal of the case management plan to resolve this issue within thirty (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. American LegalNet, Inc. www.FormsWorkFlow.com