Application For Evidentiary Hearing
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Application For Evidentiary Hearing Form. This is a Missouri form and can be use in Workers Comp.
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Tags: Application For Evidentiary Hearing, WC-MD-03, Missouri Workers Comp,
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
APPLICATION FOR EVIDENTIARY HEARING
3315 West Truman Blvd.
P.O. Box 58
Jefferson City, MO 65102-0058
Pursuant to 8 CSR 50-2.030(1)(I), this form shall be used if the total amount of the additional reimbursement sought is more than one thousand
dollars ($1,000), or this form may also be used to request an evidentiary hearing by any party aggrieved by the Division Director’s Administrative
Ruling, in a case where the additional reimbursement sought was $1,000 or less.
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Health Care Provider,
vs.
,
Employer,
and
,
Insurer
Medical Fee Dispute No:
DWC Injury No.:
-
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Employee (Patient):
Date of Accident/
Occupational Disease:
APPLICATION FOR EVIDENTIARY HEARING
The undersigned party hereby applies to the Division of Workers’ Compensation for an evidentiary hearing in the above captioned case.
Health Care Provider
Name
Employer
Name
Insurer/Third Party Administrator
Name
Respectfully submitted,
Name of Attorney
Law Firm
Address
Bar No.
Phone No.
Fax No.
E-mail Address
DIVISION USE ONLY
CERTIFICATE OF SERVICE
I, the undersigned, certify that a true and accurate copy of this Application for Evidentiary Hearing has been
mailed or hand delivered to all attorneys and/or all parties of record this
day of
, 20
.
Attorney’s Signature
Date
Attorney’s Name (Printed)
Bar No.
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 STAMP
WC-MD-03 (08-11) AI
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