Free Application for Evidentiary Hearing (WC-MD-03) - Missouri

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

APPLICATION FOR EVIDENTIARY HEARING

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

Pursuant to 8 CSR 50-2.030(1)(I), this form shall be used if the total amount of the additional reimbursement sought is more than one thousand dollars ($1,000), or this form may also be used to request an evidentiary hearing by any party aggrieved by the Division Director's Administrative Ruling, in a case where the additional reimbursement sought was $1,000 or less.

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

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Medical Fee Dispute No: DWC Injury No.: Employee (Patient): Date of Accident/ Occupational Disease: -

-

APPLICATION FOR EVIDENTIARY HEARING
The undersigned party hereby applies to the Division of Workers' Compensation for an evidentiary hearing in the above captioned case.

Health Care Provider Employer Insurer/Third Party Administrator

Name Name Name

Respectfully submitted, Name of Attorney Law Firm Address Bar No. Phone No. Fax No. E-mail Address CERTIFICATE OF SERVICE
I, the undersigned, certify that a true and accurate copy of this Application for Evidentiary Hearing has been mailed or hand delivered to all attorneys and/or all parties of record this
DIVISION USE ONLY

day of Attorney's Signature Attorney's Name (Printed) Address (if different than above)

, 20 Date

.

Bar No.

* 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 STAMP WC-MD-03 (11-06) AI