Massachusetts > Workers Comp
Health Care Provider Complaint Form 134 - Massachusetts
| Health Care Provider Complaint Form Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 134 THE COMMONWEALTH OF MASSACHUSETTS Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, Massachusetts 02114-2017 HEALTH CARE PROVIDER COMPLAINT FORM Massachusetts General Law, Chapter152ยง13(3), requires the Health Care Services Board to receive and investigate complaints from employees, employers and insurers regarding health care providers who provide services in workers' compensation claims, where the providers are alleged to have engaged in patterns of: (i) discrimination against compensation claimants; S (ii) over-utilization of procedures; S (iii) unnecessary surgery or other procedures; or S (iv) other inappropriate treatment of compensation recipients S Where the Health Care Services Board finds a pattern of abuse, it shall refer its findings to the appropriate Board of Registration. Please check (9) the appropriate box above to indicate the category to which this complaint relates. TO FILE A COMPLAINT, PLEASE PROVIDE THE FOLLOWING INFORMATION: ABOUT THE PERSON FILING THIS FORM: YOUR NAME: _________________________________________________________________________________________________________________ ADDRESS:____________________________________________________________________________________________________________________ CITY: _____________________________________________________________ STATE: ___________ ZIP CODE: _______________________ TELEPHONE:(________)__________________________________________TODAY'S DATE: _____________________________________ YOUR RELATIONSHIP TO THE COMPLAINANT: _________________________________________________________________________________________ YOUR FIRM, COMPANY OR EMPLOYER: ________________________________________________________________________________________________ ABOUT THE HEALTH CARE PROVIDER: PROVIDER'S NAME : _____________________________________________________________________________________________________________________ SPECIALTY (if known): ADDRESS: CITY: TELEPHONE: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ______________________________________________________ STATE: _________ ZIP CODE: ______________ (________) _______________________________________ THE DATE(S) OF THIS INCIDENT: _____________ Using the following space, summarize your complaint about this health care provider in 50 words or less. In addition, attach a detailed narrative of your complaint to this form describing the treatment(s), procedure(s), date(s), location(s), and other facts relevant to the complaint. _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Was this an impartial examination ordered by the Department of Industrial Accidents? YES S Was this a health care service performed by the employee's treating health care provider, YES S or a service performed by a provider chosen by an insurer or employer? YES S Reproduce as Needed Form #134 Page 1 0f 2 NO S NO S NO S Revised 7/2010 American LegalNet, Inc. www.FormsWorkFlow.com HCSB PROVIDER COMPLAINT FORM Page 2 of 2 PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT THE COMPLAINANT: THIS COMPLAINT IS BEING FILED ON BEHALF OF AN (Please Check One): EMPLOYEE.. EMPLOYER . INSURER. OTHER THE COMPlAINANT'S NAME: _________________________________________________________________________________________________ COMPLAINANT'S COMPANY:__________________________________________________________________________________________________ COMPLAINANT'S ADDRESS: __________________________________________________________________________________________________ CITY: _____________________________________________________ STATE: ___________ ZIP CODE: _____________ AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION: The following authorization for the release of medical information must be signed by the injured employee. If this complaint is filed by an insurer or employer referencing several injured employees to demonstrate a questionable pattern of care or service by a single provider, a signed authorization for release of medical information from each employee whose treatment is detailed in the complaint must be attached hereto. EMPLOYEE'S AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I hereby authorize you to furnish the Department of Industrial Accidents' Health Care Services Board with all medical information, including but not limited to, medical records, test results, reports, and/or office notes, regarding an illness or injury for which you treated me during the period of _____________________________ to _______________________________. I further authorize you to discuss with the Health Care Services Board any aspects of my illness or injury, or the treatment, diagnosis, or prognosis of my illness of injury. A photocopy of this authorization should be regarded as a valid release of the information requested. _________________________ Date ____________________________________________________________ Signature of Employee/Patient ______ - ____ - __________ Social Security No. (optional) ____________________________________________________________ Name of Employee/Patient (please print) ________________________ Date of Birth ____________________________________________________________ Address ____________________________________________ ______ ______ City/Town State Zip Code SEND THE COMPLETED COMPLAINT FORM, WITH ATTACHMENT(S), AND SIGNED EMPLOYEE AUTHORIZATION(S) TO: DEPARTMENT OF INDUSTRIAL ACCIDENTS HEALTH CARE SERVICES BOARD 1 CONGRESS ST., SUITE 100 BOSTON, MA 02114-2017 A COPY OF THIS COMPLAINT AND ALL ATTACHMENTS WILL BE FORWARDED TO THE PROVIDER. Reproduce as Needed American LegalNet, Inc. www.FormsWorkFlow.com
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