MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS ENTRY OF APPEARANCE 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 , Health Care Provider, vs. , Employer, and , Insurer ) ) ) ) ) ) ) ) ) ) ) ) Medical Fee Dispute No: Injury No.: - - Employee (Patient): Date of Accident/ Occupational Disease: ENTRY OF APPEARANCE COMES NOW, 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 attorney at law & hereby enters his/her appearance on behalf of: CERTIFICATE OF SERVICE I, the undersigned, certify that, a copy of this Entry of Appearance 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. DATE STAMP WC-200 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com