MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS’ COMPENSATION 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 REQUEST BY A HEALTH CARE PROVIDER FOR CASE STATUS INFORMATION TO FILE A MEDICAL FEE DISPUTE APPLICATION Note: If you file an “Application for Direct Payment” or an “Application for Payment of Additional Reimbursement of Medical Fees,” please return this completed form with your application. This form must be completed in its entirety for the Division to evaluate your request. Please state “unknown” if you are unable to complete any required field. Health Care Provider Information Name & Address Contact Person Name Telephone No. Employee Information Name Date of Accident/Occupational Disease Social Security No. Date Service Provided Injured Body Part(s) Employer Information Name Address Insurer Information Name Address I am requesting the Division to provide the following information (please check all that apply) Injury No. Insurance Carrier Status Update a. Report of Injury has been filed with the Division Yes No b. Claim for Compensation has been filed with the Division c. Date the case was Settled d. Date the case was Dismissed Yes No Name and Address of Claimant’s Attorney Name and Address of Employer/Insurer Attorney Please return completed form with a self-addressed stamped envelope to: DIVISION USE ONLY Missouri Division of Workers’ Compensation Attn: Medical Fee Dispute Unit P.O. Box 58 Jefferson City, MO 65102-0058 DATE STAMP WC-194 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com