OHARA Complaint/Grievance Form PLEASE COMPLETE AND SEND TO: OHARA Managed Care Attention: Lynette Huber, Director of Nursing PO Box 89527 Sioux Falls, South Dakota, 57109 Phone: 605-361-1071 or 1-800-363-4272 Fax: 605-361-1106 Information from person filing the complaint: Name: ___________________________________________________________________________ Last First Middle Initial Address: __________________________________________________________________________________________ Street City State Zip Code Telephone(day time): ______________________________Fax Number: ______________________________________ Social Security Number (Of insured or injured worker filing complaint): _________________________________________ Date of Injury: ____________________ Specialty (If Provider filing complaint): _________________________________ Insurance Carrier: ______________________________________ Claim Number: ______________________________ Employer: ____________________________________________ Telephone Number: __________________________ Employer Address: _________________________________________________________________________________ Street City State Zip Code Please describe in detail the nature of your complaint. (Please type or print clearly): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 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. Please attach any documentation/documents that you want considered in the investigation of your complaint/problem. Have you attached documents to this complaint? ____ yes ____ no __________________________________ (Print or Type) Name of Person Filing Complaint __________________________________ SIGNATURE ______________________ DATE Received at OHARA: ___________________________________