GENEX Services dba INTRACORP 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: Intracorp's Certified Managed Care Plan 2500 W. 49th Street # 206 Sioux Falls, SD 57105 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. Telephone 800-790-0220 Fax 605-334-5639 American LegalNet, Inc. www.FormsWorkFlow.com