Free Request by a Health Care Provider for Case Status Information to file a Medical Fee Dispute Application (WC-194) - Missouri



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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. Employee Information Name Social Security No. Date of Accident/Occupational Disease Injured Body Part(s) Date Service Provided Employer Information Name Address

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.

Employee Information
Name Social Security No. Date of Accident/Occupational Disease Injured Body Part(s) Date Service Provided

Employer Information
Name Address

Insurer Information
Name Address

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

File Size: 45.5 kB
Pages: 1
Date: December 26, 2007
File Format: PDF
State: Missouri
Category: Workers Compensation
Author: ES0691
Word Count: 236 Words, 1,541 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dolir.mo.gov/wc/forms/194-AI.pdf