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OHARA Complaint-Grievance Form. This is a South Dakota form and can be use in Workers Compensation.
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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: ___________________________________
