Dispute Resolution Form Alaris Group DBA Paradigm

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: Marijo Storment, The ALARIS Group, Inc. PO Box 207, Garretson, SD 57030. 605-594-8160. It is the goal of the case managemnte 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.