MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS REQUEST FOR AWARD ON UNDISPUTED FACTS IN REGARD TO APPLICATION FOR DIRECT PAYMENT , Health Care Provider, vs. , Employer, and , Insurer ) ) ) ) ) ) ) ) ) ) ) ) 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 Medical Fee Dispute No: Injury No.: - - Employee (Patient): Date of Accident/ Occupational Disease: REQUEST FOR AWARD ON UNDISPUTED FACTS Employer hereby requests that an Administrative Law Judge of the Division of Workers' Compensation issue an award denying the APPLICATION FOR DIRECT PAYMENT filed herein by (name of health care provider) on the ground that the health care services for which direct payment is being sought were not authorized by Employer or its Insurer. In support of this request, Employer states that there is no genuine issue of fact necessitating an evidentiary hearing in regard to the APPLICATION FOR DIRECT PAYMENT, and that the following facts are undisputed (attach additional sheets, if necessary): In support of the undisputed facts listed above, Employer attaches the following exhibits (attach additional sheets, if necessary): Please identify each exhibit by letter "A," "B," etc. and by general description of the document. Employer/Insurer Signature & Date Employer/Insurer Attorney's Signature & Date Employer Address & Telephone No. Attorney's Address & Telephone No. CERTIFICATE OF SERVICE I, the undersigned, certify that a true and accurate copy of this Request for Award on Undisputed Facts 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) DIVISION USE ONLY Date Bar No. DATE STAMP WC-201 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com