OHARA Complaint-Grievance Form

OHARA Complaint/Grievance Form PLEASE COMPLETE AND SEND TO: OHARA Managed Care Attention: Lynette Huber, Director of Nursing 3900 Technology Circle Suite #4 Sioux Falls, South Dakota 57106 605-361-1071 or 1-800-363-4272 Fax: 605-361-1106 Information from person filing the complaint: Name: ______________________________________________________________________________ Last First Middle Initial Address: __________________________________________________________________________________________ Street City State Zip Code Telephone(day time): ______________________________ Fax Number: _____________________________________ Social Security Number (Of insured or injured worker filing complaint): ________________________________________ Date of Injury: ____________________ Specialty (If Provider filing complaint): ________________________________ Insurance Carrier: ______________________________________ Claim Number: _____________________________ Employer: ____________________________________________ Telephone Number: __________________________ Employer Address: ________________________________________________________________________________ Street City State Zip Code Please describe in detail the nature of your complaint. (Please type or print clearly): _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Please attach any documentation/documents that you want considered in the investigation of your complaint/problem. Have you attached documents to this complaint? ____ yes ____ no __________________________________ (Print or Type) Name of Person Filing Complaint __________________________________ ______________________ SIGNATURE DATE Received at OHARA: ___________________________________