MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION
REQUEST FOR CERTIFICATION
Completion of this form indicates that the rehabilitation provider is interested in being contacted by the Division regarding certification. General Information: Facility Name: Address:
**** For multi-site facilities, please attach a list of all locations.
Contact Person: Phone: Medical Director: Date Facility Established: List date of latest certification (if applicable): JCAHO CARF Medicare Yes No Other (specify) If "Yes," please provide date: Fax: Years of Experience: Type of Facility: Inpatient Outpatient
Has facility ever been certified by the Division?
What percentage of your client base is workers' compensation?
Signature of person completing form
Return completed form to: Fax: 573-522-1623 Phone: 573-526-3876 Mail: Attn: Rhonda Forck Missouri Division of Workers' Compensation P. O. Box 58 Jefferson City, Missouri 65102-0058
Relay Missouri: 1-800-735-2966 (TDD) 1-800-735-2466 (Voice) www.dolir.mo.gov/wc
WCR-8 (07-03) AI