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. Venue
ANSWER TO APPLICATION FOR DIRECT PAYMENT
NOTE: No Answer to Application for Direct Payment is required. However, if the Employer/Insurer would like to file an Answer this form should be utilized.
1. Health Care Provider Name Mailing Address City State Zip Code
2. Employee (Patient's) Name
3. Name of Employer
4. Name of Insurer/Third Party Administrator
5. Name all authorized providers of medical aid:
6. Date of Accident/Occupational Disease
7. All of the statements or allegations in the "Application for Direct Payment" are admitted except the following: Please describe below each statement or allegation in the "Application for Direct Payment" that is being disputed, the reason why it is being disputed and the facts thereto. Please list all affirmative defenses. If needed, attach sheet with additional information.
8. Employer's Signature
9. Insurer's Signature
10. Attorney Signature
Attorney Name (Type or Print)
Attorney E-mail Address
Attorney Mailing Address
Attorney Phone No. Attorney Fax No.
CERTIFICATE OF SERVICE
I, the undersigned, certify that a true and accurate copy of this Answer to 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) Date Bar No.
DIVISION USE ONLY
DATE STAMP WC-199 (11-06) AI