MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION
REQUEST FOR DISMISSAL OF APPLICATION FOR DIRECT PAYMENT
, Health Care Provider, vs. , Employer, and , Insurer ) ) ) ) ) ) ) ) ) ) ) )
3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058
Medical Fee Dispute No: Injury No.: -
Employee (Patient): Date of Accident/ Occupational Disease:
REQUEST FOR DISMISSAL OF APPLICATION FOR DIRECT PAYMENT The undersigned health care provider hereby requests that the Division of Workers' Compensation of the State of Missouri dismiss its Application for Direct Payment on the following ground: The medical fee dispute has been resolved or otherwise compromised and settled. Date Amount The dispute does not involve the type of medical fee dispute applicable to the administrative process involved in the filing of an Application for Direct Payment. The health care provided by the undersigned was not authorized by the employer or insurer.
Health Care Provider Health Care Provider's Attorney Address and Telephone Date
CERTIFICATE OF SERVICE
I, the undersigned, certify that a true and accurate copy of this Request for Dismissal of Application for Direct Payment has been mailed or hand delivered to all attorneys and/or all parties of record this day of , 20 .
DIVISION USE ONLY
Attorney's Signature Attorney's Name (Printed) Address (if different than above)
Date Bar No.
WC-MD-10 (01-09) AI