Would You Like to Receive Assistance from the Office of the Appeals Advisor Yes No

/ G040
REQUEST FOR REVIEW

Name ______
Address ______
City/Town ______Postal Code ______Telephone Number ______

Note: You have one year from the date of the decision to submit your Request for Review.

For more information on our collaborative review process, please visit our website at www.wcb.ab.ca/claims/review-and-appeals/.

STEP ONE: Please ensure you have a copy of your file. If you feel you have new information not already on your file, please send this information to your file. Be sure to provide any additional information you feel could impact the decision you disagree with.

Would you like to receive assistance from the Office of the Appeals Advisor Yes No

If you are an employer, you may be able to access assistance from the Employer Appeal Consulting Service. Visit our website for more information at www.wcb.ab.ca/claims/review-and-appeals/for-employers/emp_appeal.asp

Do you already have a representative to act on your behalf? If yes, representative name

STEP TWO: Contact the person who made the decision. If you do not understand or agree with a decision, ask for a full explanation. For CLAIMS: Contact your adjudicator or case manager. For ACCOUNTS: Contact the customer contact representative, auditor, underwriter, etc. You may be asked to provide them with additional information that may help to change the decision. If you have new information that we may not be aware of, you would provide it in this step. If you still disagree with the decision, please request to speak to the supervisor.

Have you completed step one and two? Yes No If yes, please proceed to step three.

STEP THREE: Request a review. Proceed with this step ONLY if you have completed step one and two and you still have concerns. To start your request, you must complete this form.

I disagree with the decision concerning this claim or account and request the decision be reviewed.

A. What is the decision you wish to have reviewed? (be as specific as possible)

Temporary Total Disability Benefits
medical aid
wage loss (ELP, TEL, ELS, TPD) / NELP
vocational rehabilitation benefits
other, please specify
______
______
______

B. What is the date of the letter sent to you that explains the decision?

______
______

C. What are your reasons for requesting a review of this decision? (be as specific as possible)

______
______
Signed ______/ Date ______

The information requested on this form is collected under Sections 33 (a) and 33 (c) of the Freedom of Information and protection of Privacy Act for the purpose of making a formal request for review of a claim decision. If you have questions, please call the Customer Contact Centre as noted at the top of this form.

G – 040 REV JUN 2016