Request For Dismissal Of Application For Direct Payment
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Request For Dismissal Of Application For Direct Payment Form. This is a Missouri form and can be use in Workers Comp.
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Tags: Request For Dismissal Of Application For Direct Payment, WC-MD-10, Missouri Workers Comp,
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
REQUEST FOR DISMISSAL OF APPLICATION
FOR DIRECT PAYMENT
,
Health Care Provider,
vs.
,
Employer,
and
,
Insurer
)
)
)
)
)
)
)
)
)
)
)
)
Medical Fee Dispute No:
Injury No.:
3315 West Truman Blvd.
P.O. Box 58
Jefferson City, MO 65102-0058
-
-
Employee (Patient):
Date of Accident/
Occupational Disease:
REQUEST FOR DISMISSAL OF APPLICATION FOR DIRECT PAYMENT
The undersigned health care provider hereby requests that the Division of Workers’ Compensation of the State of Missouri dismiss its
Application for Direct Payment on the following ground:
The medical fee dispute has been resolved or otherwise compromised and settled.
Date
Amount
The dispute does not involve the type of medical fee dispute applicable to the administrative process involved in the
filing of an Application for Direct Payment.
The health care provided by the undersigned was not authorized by the employer or insurer.
Health Care Provider
Health Care Provider’s Attorney
Address and Telephone
Date
CERTIFICATE OF SERVICE
DIVISION USE ONLY
I, the undersigned, certify that a true and accurate copy of this Request for Dismissal of Application for
Direct Payment has been mailed or hand delivered to all attorneys and/or all parties of record this
day of
, 20
.
Attorney’s Signature
Date
Attorney’s Name (Printed)
Bar No.
Address (if different than above)
DATE STAMP
WC-MD-10 (08-11) AI
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