MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION
HEALTH CARE PROVIDER'S RESPONSE TO REQUEST FOR AWARD ON UNDISPUTED FACTS IN REGARD TO APPLICATION FOR DIRECT PAYMENT
3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058
Pursuant to 8 CSR 50-2.030(2)(I)(b) the health care provider shall file its response to the award on undisputed facts within thirty days.
, Health Care Provider, vs. , Employer, and , Insurer
) ) ) ) ) ) ) ) ) ) ) )
Medical Fee Dispute No: Injury No.: -
Employee (Patient): Date of Accident/ Occupational Disease:
RESPONSE TO REQUEST FOR AWARD ON UNDISPUTED FACTS Health Care Provider
(name of health care provider)
herein, for its response to the
REQUEST FOR AWARD ON UNDISPUTED FACTS filed by Employer/Insurer states as follows (attach additional sheets, if necessary):
In support of its statements, Health Care Provider attaches the following exhibits (attach additional sheets, if necessary): Please identify each exhibit by numbers "1," "2," etc. and by general description of the document.
Health Care Provider Signature & Date Health Care Provider's Attorney Signature & Date (if applicable)
Health Care Provider Address & Telephone No. Attorney's Address & Telephone No.
CERTIFICATE OF SERVICE
I, the undersigned, certify that a true and accurate copy of this Response to Request for Award on Undisputed Facts 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.
DATE STAMP WC-202 (11-06) AI