MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS APPLICATION FOR DIRECT PAYMENT Please check the appropriate box. 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 W.C. Injury Number Authorization potentially in dispute Authorization has been provided Original Amended Medical Fee Dispute No. Use this form only if you are a hospital, physician or other health care provider that has provided services to an employee, which have been authorized in advance by the employer or insurer or where the authorization is potentially in dispute. Please note that pursuant to § 287.140.13 (6) RSMo, the services provided must relate to a work-related injury under the workers' compensation law. 1. Health Care Provider Name Address (Street, City & County) State ZIP Code Telephone No. 2. Employee (Patient's) Name Address (Street, City & County) State ZIP Code Date of Accident/Occupational Disease Social Security No. 3. Name of Employer Address (Street, City & County) State ZIP Code Telephone No. 4. Name of Insurer/Third Party Administrator Address (Street, City & County) State ZIP Code Telephone No. 5. Brief Description of Disputed Services Rendered Date Services Provided Name and Title of Person Who Authorized Services Date Authorization was Given Amount Billed Amount Claimed A. B. C. D. E. $ $ $ $ $ $ $ $ $ $ Total Amount Claimed $ (If needed, attach sheet with additional information.) 6. Signature of Health Care Provider* Attorney Address Attorney Telephone No. 7. Health Care Provider's Attorney Signature & Date* Bar No. Attorney E-mail Address Attorney Fax No. CERTIFICATE OF SERVICE I, the undersigned, certify that a true and accurate copy of this 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) * 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 Bar No. DIVISION USE ONLY DATE STAMP WC-MD-01 (03-12) AI American LegalNet, Inc. www.FormsWorkFlow.com