Free Application for Direct Payment (WC-MD-01) - Missouri

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

3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 W.C. Injury Number Medical Fee Dispute No.

APPLICATION FOR DIRECT PAYMENT
Please check the appropriate box.

Authorization potentially in dispute Authorization has been provided

Original

Amended

Use this form only if you are a hospital, physician or other health care provider that has provided services to an employee, which have been authorized in advance by the employer or insurer or where the authorization is potentially in dispute. Please note that pursuant to § 287.140.13 (6) RSMo, the services provided must relate to a work-related injury under the workers' compensation law.
1. Health Care Provider Name Address (Street, City & County) State Zip Code Telephone No.

2. Employee (Patient's) Name

Address (Street, City & County)

State

Zip Code

Date of Accident/Occupational Disease Social Security No.

3. Name of Employer

Address (Street, City & County)

State

Zip Code

Telephone No.

4. Name of Insurer/Third Party Administrator

Address (Street, City & County)

State

Zip Code

Telephone No.

5.

Brief Description of Disputed Services Rendered

Date Services Provided

Name and Title of Person Who Authorized Services

Date Authorization was Given

Amount Billed

Amount Claimed

A. B. C. D. E.

$ $ $ $ $

$ $ $ $ $

Total Amount Claimed $ (If needed, attach sheet with additional information.)
6. Signature of Health Care Provider* Attorney Address Attorney Telephone No.

7. Health Care Provider's Attorney Signature & Date*

Bar No. Attorney E-mail Address

Attorney Fax No.

CERTIFICATE OF SERVICE
I, the undersigned, certify that a true and accurate copy of this Application for Direct Payment 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) * Please be advised that corporations and limited liability companies appearing before the Division must be represented by an attorney licensed in the State of Missouri. See Reed v. Labor and Ind. Rel. Commn., 789 S.W.2d 19, 20 (Mo. banc 1990). * If the Health Care Provider is a corporation or a LLC, and this Application is not signed by an attorney, this Application will be rejected. Date Bar No.

DIVISION USE ONLY

DATE STAMP

WC-MD-01 (11-06) AI