South Dakota > Workers Compensation
Dispute Resolution Form (CorVel Corporation) - South Dakota
| Dispute Resolution Form (CorVel Corporation) Form. This is a South Dakota form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
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 Scheel, CorVel Corporation, 3900 West Technology Circle, Suite 2, Sioux Falls, SD 57106 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 mbe made to the South Dakota Departmay ent of Labor.
|
|||||||
