Request By A Health Care Provider For Case Status Information
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Request By A Health Care Provider For Case Status Information Form. This is a Missouri form and can be use in Workers Comp.
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Tags: Request By A Health Care Provider For Case Status Information, WC-194, Missouri Workers Comp,
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
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 (04-12) AI
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