Free Entry of Appearance (WC-200) - Missouri

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION

ENTRY OF APPEARANCE

3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058

, Health Care Provider, vs. , Employer, and , Insurer

) ) ) ) ) ) ) ) ) ) ) )

Medical Fee Dispute No: Injury No.: -

-

Employee (Patient): Date of Accident/ Occupational Disease:

ENTRY OF APPEARANCE COMES NOW, Health Care Provider Name Employer Name Insurer/Third Party Administrator Name Respectfully submitted, Name of Attorney Law Firm Address Bar No. Phone No. Fax No. E-mail Address
DIVISION USE ONLY

attorney at law & hereby enters his/her appearance on behalf of:

CERTIFICATE OF SERVICE
I, the undersigned, certify that, a copy of this Entry of Appearance has been mailed or hand delivered to all attorneys and/or all parties of record this day of , 20 . Attorney's Signature Attorney's Name (Printed) Address (if different than above) Date Bar No.

DATE STAMP WC-200 (08-06) AI