Form 3160-0019 - Formal Grievance Form printable pdf download

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: ___________________________________________________________________________________________________

Office 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 filed? (Nature of the problem): __________________________________________________________

__________________________________________________________________________________________________________

Has a grievance been previously filed? ___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 dissatisfied with the final decision of the grievance committee, the dissatisfied party has the right to file a petition for

Benefits 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, files 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 3/02 (02-151)