Get 02-151 State Grievance Form - Fl - Summit

The 02-151 State Grievance Form is an essential document for individuals seeking formal review regarding dissatisfaction with medical care issues related to workers' compensation in Florida. This guide provides step-by-step instructions to help users effectively complete the form online.

Follow the steps to complete the grievance form online.

1. Click ‘Get Form’ button to access the 02-151 State Grievance Form and open it in the editor.
2. Indicate the party filing the grievance by selecting either 'Provider,' 'Injured Worker,' or 'Designated Representative.' If applicable, specify if the representative is a 'Family Member,' 'Attorney,' or 'Other.'
3. Enter the date of injury in the specified field.
4. Fill in the injured worker’s or provider’s name, social security number, address, home telephone, and work/alternate phone in the appropriate sections.
5. If someone other than the injured worker or provider will be contacted, include their name and telephone number.
6. Provide the primary care or treating physician’s name and address along with their office telephone number.
7. In the large text area provided, describe the nature of the grievance. Include as much detail as possible regarding the problem and desired outcome. If needed, use additional sheets with your name and social security number on each page.
8. Indicate whether a grievance has been previously filed by checking 'Yes' or 'No.' If yes, provide the date it was sent.
9. Outline the action you wish to see taken regarding your grievance in the provided section.
10. Answer whether you have received any information regarding your rights and responsibilities under workers' compensation managed care by checking 'Yes' or 'No.'
11. Complete the form by signing and dating it in the designated areas. Ensure that the grievance coordinator also signs it if applicable.
12. Once all fields are completed, save your changes. You may download, print, or share the completed form as needed.

Begin the formal grievance process and complete your document online today.