Request For Dismissal Of Notice Of Services Provided Request For Direct Payment
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Request For Dismissal Of Notice Of Services Provided Request 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 Notice Of Services Provided Request For Direct Payment, WC-MD-10, Missouri Workers Comp,
COURT
NTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.... ..
:
Index No.
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
:
Calendar No.
DIVISION OF WORKERS’ COMPENSATION
Plaintiff(s)
-against-
:
JUDICIAL SUBPOENA
:
)
HEALTH CARE PROVIDER
) :
)
vs.
) :
)
Defendant(s)
) :
.................................................
EMPLOYER
)
)
)
INSURER STATE OF NEW YORK
)
PEOPLE OF THE
IN RE: Medical Fee Dispute No:
Employee (Patient):
Employee (Patient) Social Security No:
Date of Accident/Incident:
Workers’ Comp Injury No:
REQUEST FOR DISMISSAL OF NOTICE OF SERVICES PROVIDED
REQUEST FOR DIRECT PAYMENT
The undersigned party hereby requests that the Division of Workers’ Compensation of the State of Missouri dismiss its application
ETINGS:entitled Notice of Services Provided & Request for Direct Payment on the following grounds:
WE COMMAND The medicalall business and excuses beingotherwise compromised and of you attend before
YOU, that fee dispute has been resolved or laid aside, you and each settled.
,
onorable
at the
Date
Amount Court
located at
y of
m
, on the The dispute does not involve the type of medical fee dispute applicable to the administrative process involved in the
day of
, 20
, at
o'clock in the
noon, and at any recessed
ourned date, to testify filinggive evidence as a witness of Services Provided & Request for Direct Payment.
and of an Application for Notice in this action on the part of the
The health care provided by the undersigned was not authorized by the employer or insurer.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
arty on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
of your failure to comply.
Health Care Provider
Witness, Honorable
in
County,
, one of the Justices of the
day of
, 20
Health Care Provider’s Attorney
Address and Telephone
Date:
(Attorney must sign above and type name below)
Attorney(s) OF
CERTIFICATE for SERVICE
The undersigned hereby certifies that a true and accurate copy of the Request for Dismissal of Notice of Services Provided &
Request for Direct Payment has been mailed by first-class mail, postage prepaid or hand delivered to
(name and address of opposing party or opposing party’s attorney)
Office and P.O. Address
this
day of
, 20
.
Telephone No.:
Facsimile No.:
E-Mail Address: Petitioner or Petitioner’s Attorney
Mobile Tel. No.:
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WC-MD-10 (2-2000) AI
