Dispute Resolution Form (DynaPro)

DISPUTE RESOLUTION FORM Date: From: Name: Address: Telephone Number: RE: Claimant Name: Date of Injury: Claim Number: Employer: Description and Summary of Dispute: Please attach any supporting documentation that should be considered. Please submit to: Mary Soukup SD MCO Administrator DynaPro Enterprises, Inc. 4009 E. Huntington Street Sioux Falls, SD 57103 Telephone: 888-336-7577 Fax: 605-336-7579 It is the goal of the case management plan to resolve this issue within 30 days of receipt of this form. At that time, should resolution not be achieved, or there continues to be dissatisfaction of the results, an appeal may be made to the South Dakota Department of Labor. 4009 E. Huntington Street Sioux Falls, SD 57103 Phone: (605) 336-7577 Fax: (605) 336-7579 American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com