MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS REQUEST FOR CERTIFICATION 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 573-751-4231 www.labor.mo.gov/DWC Completion of this form indicates that the rehabilitation provider is interested in being contacted by the Division regarding certification. General Information: Facility Name: Address: **** For multi-site facilities, please attach a list of all locations. Contact Person: Phone: E-mail: Medical Director: Date Facility Established: List date of latest certification (if applicable): JCAHO CARF Medicare Yes No Other (specify) If "Yes," please provide date: Years of Experience: Type of Facility: Inpatient Outpatient Fax: Has facility ever been certified by the Division? What percentage of your client base is workers' compensation? Signature of person completing form Title Date Return completed form to: Fax: 573-522-1623 Phone: 573-526-3876 Mail: Attn: Physical Rehabilitation Missouri Division of Workers' Compensation P. O. Box 58 Jefferson City, MO 65102-0058 WCR-8 (10-11) AI American LegalNet, Inc. www.FormsWorkFlow.com