OSDH Form 833 "Informal Dispute Resolution Request Form" - Oklahoma

What Is ODH Form 833?

This is a legal form that was released by the Oklahoma State Department of Health - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2021;
  • The latest edition provided by the Oklahoma State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of ODH Form 833 by clicking the link below or browse more documents and templates provided by the Oklahoma State Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download OSDH Form 833 "Informal Dispute Resolution Request Form" - Oklahoma

Download PDF

Fill PDF online

Rate (4.5 / 5) 62 votes
Page background image
Oklahoma State Department of Health
Long Term Care
123 Robert S Kerr Ave, Suite 1702
Oklahoma City, OK 73012-6406
p. (405) 426-8200
f. (405) 900-7594
Informal Dispute Resolution Request Form
Authorized by Oklahoma State Statute In the Nursing Home Care Act
To access this form and the IDR process online at the Health Department web site
click here.
Skilled nursing facilities (SNF), nursing facilities (NF), skilled nursing facilities/nursing facilities (SNF/NF), and
intermediate care facilities for individuals with intellectual disabilities (ICF/IID) must complete this form to dispute
cited deficiencies. If you have any questions, contact the IDR Coordinator by telephone at (405) 426-8200 or via e-mail
at IDRCoordinator@health.ok.gov.
Submission
Complete this form, attach all documentary evidence relevant to each disputed deficiency and submit within ten (10)
calendar days of receiving the official Statement of Deficiencies. Submit this form to Oklahoma State Department
of Health, Long Term Care, Attention: IDR Coordinator, 123 Robert S Kerr Ave, Suite 1702, Oklahoma City, OK
73102-6406. An IDR will not be granted when a request form is incomplete or inaccurate. Documentary
evidence submitted past the required timeframe will not be considered.
IDR Type: (Check One)
Face-to-Face Meeting 
Record Review 
Telephone/Virtual Conference 
Facility Name: _________________________________________
Facility ID:
______________________________
Facility Administrator:
___
________________________________
E-mail:
__________________________________
Mailing Address:
___
____________________________________
Telephone Number: (
)
__________________
City: _____________________________
Zip Code:
___________
Facsimile Number: (
)
__________________
Date Statement of Deficiencies Received: ______/______/______
Survey Exit Date:
______/______/______
Dispute Description
Tag Number
S/S
Explanation of Dispute
(Why is facility disputing the deficiency? List reason for each.)
A separate sheet may be attached, but must clearly identify the following: facility name, ID, survey exit date, tag number, scope &
severity, and the explanation of dispute. All documentary evidence submitted must also identify these items.
1. __________
____
___________________________________________________________________
______________________________________________________________________
__________________
2. __________
____ ___________________________________________________________________
________________________________________________________________________________________
3. __________
____ ___________________________________________________________________
________________________________________________________________________________________
4. __________
____ ___________________________________________________________________
___________________________________________________
_____________________________________
Submitted by: ___________________________________
Date:
______/______/ _______
Oklahoma State Department of Health
ODH Form 833
Protective Health Services
(Rev. 05/2021)
Oklahoma State Department of Health
Long Term Care
123 Robert S Kerr Ave, Suite 1702
Oklahoma City, OK 73012-6406
p. (405) 426-8200
f. (405) 900-7594
Informal Dispute Resolution Request Form
Authorized by Oklahoma State Statute In the Nursing Home Care Act
To access this form and the IDR process online at the Health Department web site
click here.
Skilled nursing facilities (SNF), nursing facilities (NF), skilled nursing facilities/nursing facilities (SNF/NF), and
intermediate care facilities for individuals with intellectual disabilities (ICF/IID) must complete this form to dispute
cited deficiencies. If you have any questions, contact the IDR Coordinator by telephone at (405) 426-8200 or via e-mail
at IDRCoordinator@health.ok.gov.
Submission
Complete this form, attach all documentary evidence relevant to each disputed deficiency and submit within ten (10)
calendar days of receiving the official Statement of Deficiencies. Submit this form to Oklahoma State Department
of Health, Long Term Care, Attention: IDR Coordinator, 123 Robert S Kerr Ave, Suite 1702, Oklahoma City, OK
73102-6406. An IDR will not be granted when a request form is incomplete or inaccurate. Documentary
evidence submitted past the required timeframe will not be considered.
IDR Type: (Check One)
Face-to-Face Meeting 
Record Review 
Telephone/Virtual Conference 
Facility Name: _________________________________________
Facility ID:
______________________________
Facility Administrator:
___
________________________________
E-mail:
__________________________________
Mailing Address:
___
____________________________________
Telephone Number: (
)
__________________
City: _____________________________
Zip Code:
___________
Facsimile Number: (
)
__________________
Date Statement of Deficiencies Received: ______/______/______
Survey Exit Date:
______/______/______
Dispute Description
Tag Number
S/S
Explanation of Dispute
(Why is facility disputing the deficiency? List reason for each.)
A separate sheet may be attached, but must clearly identify the following: facility name, ID, survey exit date, tag number, scope &
severity, and the explanation of dispute. All documentary evidence submitted must also identify these items.
1. __________
____
___________________________________________________________________
______________________________________________________________________
__________________
2. __________
____ ___________________________________________________________________
________________________________________________________________________________________
3. __________
____ ___________________________________________________________________
________________________________________________________________________________________
4. __________
____ ___________________________________________________________________
___________________________________________________
_____________________________________
Submitted by: ___________________________________
Date:
______/______/ _______
Oklahoma State Department of Health
ODH Form 833
Protective Health Services
(Rev. 05/2021)