Request For Dismissal Of Application For Payment of Additional Reimbursements Of Medical Fees
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Request For Dismissal Of Application For Payment of Additional Reimbursements Of Medical Fees Form. This is a Missouri form and can be use in Workers Comp.
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Tags: Request For Dismissal Of Application For Payment of Additional Reimbursements Of Medical Fees, WC-MD-05, Missouri Workers Comp,
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
3315 West Truman Blvd.
P.O. Box 58
Jefferson City, MO 65102-0058
REQUEST FOR DISMISSAL OF APPLICATION
FOR PAYMENT OF ADDITIONAL
REIMBURSEMENT OF MEDICAL FEES
,
Health Care Provider,
vs.
,
Employer,
and
,
Insurer
)
)
)
)
)
)
)
)
)
)
)
)
Medical Fee Dispute No:
Injury No.:
-
-
Employee (Patient):
Date of Accident/
Occupational Disease:
REQUEST FOR DISMISSAL OF APPLICATION FOR PAYMENT OF
ADDITIONAL REIMBURSEMENT OF MEDICAL FEES
The undersigned health care provider hereby requests that the Division of Workers’ Compensation of the State of Missouri dismiss its
Application for Payment of Additional Reimbursement of Medical Fees 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 Payment of Additional Reimbursement of Medical Fees.
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
Payment of Additional Reimbursement of Medical Fees 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-05 (04-12) AI
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