MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION
3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058
REQUEST BY A HEALTH CARE PROVIDER FOR CASE STATUS INFORMATION TO FILE A MEDICAL FEE DISPUTE APPLICATION
Note: If you file an "Application for Direct Payment" or an "Application for Payment of Additional Reimbursement of Medical Fees," please return this completed form with your application. This form must be completed in its entirety for the Division to evaluate your request. Please state "unknown" if you are unable to complete any required field.
Health Care Provider Information
Name & Address Contact Person Name Telephone No.
Name Social Security No. Date of Accident/Occupational Disease Injured Body Part(s) Date Service Provided
I am requesting the Division to provide the following information (please check all that apply)
Injury No. Insurance Carrier
Status Update a. Report of Injury has been filed with the Division b. Claim for Compensation has been filed with the Division c. Date the case was Settled d. Date the case was Dismissed Name and Address of Claimant's Attorney Yes Yes No No
Name and Address of Employer/Insurer Attorney
Please return completed form with a self-addressed stamped envelope to: Missouri Division of Workers' Compensation Attn: Medical Fee Dispute Unit P.O. Box 58 Jefferson City, MO 65102-0058
DIVISION USE ONLY
DATE STAMP WC-194 (11-06) AI