Form 3160-0019 Formal Grievance Form - Florida Workers' Compensation Managed Care Arrangement

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Florida Workers’ Compensation Managed Care Arrangement
FORMAL GRIEVANCE FORM
An Injured Worker or Health Care Provider shall use this form to request a formal review about dissatisfaction with medical care issues provided by or on behalf
of a Workers’ Compensation Managed Care Arrangement.
This Grievance is Filed by: ___ Provider ___ Injured Worker or a Designated Representative: __ Family Member __ Attorney __ Other
Date of Injury___________
INJURED WORKER’S/ PROVIDER’S NAME: ____________________________________________________________________
Social Security Number ________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Home Telephone: ___________________________________Work/Alternate Phone: ______________________________________
Contact if other than injured worker or provider____________________________________ Telephone # _______________________
PRIMARY CARE/TREATING PHYSICIAN: _______________________________________________________________________
Address: ____________________________________________________________________________________________________
Offi ce Telephone: _____________________________________________________________________________________________
If the space provided below is inadequate for you to fully explain your concern or the action you desire, continue your statement on a sheet of plain paper.
Please be sure your name and social security number appear on each page of any attachment.
Why is this grievance being fi led? (Nature of the problem): ____________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Has a grievance been previously fi led? ___YES___NO
IF YES, Date sent? ______________________________________________
What Action Would You Like to See Taken? ________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Have you received any information regarding your rights and responsibilities under WC Managed Care? Yes ____ No ____
INTENT: The grievance procedure is intended to be self-executing and easy to use. An injured worker may call the grievance coordinator directly without
completing this form. The grievance coordinator may complete the form for the injured worker. A review regarding the requested medical care will begin
immediately, and a decision made within 44 days of receipt unless additional information is required from outside the service area. The review period may be
extended by mutual agreement between the injured worker and the grievance coordinator, with notice provided to all other participating parties.
The injured worker’s participation in the grievance process is important to the resolution of medical issues. Individuals reviewing the grievance may
need to speak directly with and receive input from the injured worker. If the injured worker is unable to participate actively in the grievance process, a patient
advocate may participate on behalf of the injured worker.
If the injured worker, employer, or carrier is dissatisfi ed with the fi nal decision of the grievance committee, the dissatisfi ed party has the right to fi le a petition
for Benefi ts with the Florida Division of Workers’ Compensation.
Any person who, knowingly and with intent to injure, defraud, or deceive any employee, insurance company, or self-insured program, fi les a statement of claim
containing any false or misleading information is guilty of a felony of the third degree.
Form Completed by: ___________________________________________________
____________________________________
Injured Worker/ Provider/ Other
Date Form Completed/Signed
_____________________________________________________________________
____________________________________
Signature of Grievance Coordinator
Date Grievance Coordinator Signed
MAIL TO: Summit • P.O. Box 2928 • Lakeland, FL 33806-2928
Form 3160-0019 November, 2000
SCM0321

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