Get Travelers Grievance Form 2004-2024

Form Completed by Signature of Grievance Coordinator Date Form Completed/Signed Date Grievance Coordinator Signed MAIL TO The Workers Compensation Managed Care Arrangement Travelers ATTN GRIEVANCE COORDINATOR P. Florida Workers Compensation Managed Care Arrangement See Reverse of Form for Information Regarding Filing a Grievance FORMAL GRIEVANCE FORM An Injured Worker or Health Care Provider shall use this from to request a formal review about dissatisfaction with medical care issues provided by or on behalf of a Workers Compensation Managed Care Arrangement. The Grievance is being filed by Provider Injured Worker / 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 PRIMARY CARE / TREATING PHYSICIAN 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 Form 3160-0019 November 2000 Rev* 2/2010 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 If the injured worker employer of 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 selfinsured program files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. Florida Workers Compensation Managed Care Arrangement See Reverse of Form for Information Regarding Filing a Grievance FORMAL GRIEVANCE FORM An Injured Worker or Health Care Provider shall use this from to request a formal review about dissatisfaction with medical care issues provided by or on behalf of a Workers Compensation Managed Care Arrangement. The Grievance is being filed by Provider Injured Worker / 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 PRIMARY CARE / TREATING PHYSICIAN 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.