MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS APPLICATION FOR ADMINISTRATIVE RULING 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 Pursuant to 8 CSR 50-2.030(1)(H) if the total amount of the additional reimbursement sought is one thousand dollars ($1,000) or less, either party may use this form to file a request for administrative ruling that initiates the administrative ruling procedure. All parties shall participate in the administrative ruling procedure. , Health Care Provider, vs. , Employer, and , Insurer ) ) ) ) ) ) ) ) ) ) ) ) Medical Fee Dispute No: DWC Injury No.: Employee (Patient): Date of Accident/ Occupational Disease: - - APPLICATION FOR ADMINISTRATIVE RULING Total Amount Disputed $ The undersigned party hereby applies to the Division of Workers' Compensation for an Administrative Ruling 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 Administrative Ruling 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-214 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com