Get Travelers Grievance Form 2004-2025

The Travelers Grievance Form is a crucial document for those seeking a formal review of medical care issues associated with Workers’ Compensation Managed Care. This guide will provide you with step-by-step instructions to help you fill out the form effectively and efficiently, ensuring your concerns are clearly articulated.

Follow the steps to complete the Travelers Grievance Form online

1. Press the ‘Get Form’ button to access the Travelers Grievance Form and open it in your preferred document editor.
2. Indicate who is filing the grievance by selecting the appropriate option. This could be a provider, injured worker, designated representative, family member, attorney, or another party.
3. Fill in the date of injury. Ensure you enter the correct date format as specified in the form.
4. Provide the injured worker’s or provider’s name clearly in the designated space.
5. Enter the Social Security number in the appropriate field, ensuring accuracy for identification purposes.
6. Complete the address, home telephone, and work/alternate phone fields to establish contact.
7. If the contact person is not the injured worker or provider, include their contact number.
8. List the primary care or treating physician’s name, address, and office telephone number in the provided sections.
9. If more space is needed to explain your concern, continue on a separate sheet of plain paper, making sure to include your name and Social Security number on each page.
10. Describe the nature of the problem that is prompting the grievance in the specified area.
11. Indicate whether a grievance has been previously filed by checking 'yes' or 'no,' and if yes, provide the date sent.
12. Clearly state what action you would like to see taken regarding your grievance.
13. Confirm whether you have received information about your rights and responsibilities under Workers’ Compensation Managed Care by selecting 'yes' or 'no'.
14. Complete the form by entering your name, and if applicable, the signature of the grievance coordinator, along with the date completed and signed.
15. After verifying all information is accurate, you can save changes, download the completed document, print it, or share the form as necessary.

We encourage you to complete the Travelers Grievance Form online to ensure your concerns are addressed promptly.