Dispute Resolution Form (Stubbe Dakota Case Management)

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 document ation that should be considered. Please submit to: The Administrator of the Certified Case Management Plan Jerry Gravatt Stubbe Dakota Case Management 329-A East St. Joseph Street Rapid City, SD 57701 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.