Request For Award On Undisputed Facts {WC-297}

3315 West Truman Boulevard, Room 131 P.O. Box 58 Jefferson City, MO 65102-0058 Phone: 573-751-4231 Fax: 573-751-2012 www.labor.mo.gov/DWC E-mail: workerscomp@labor.mo.gov , Health Care Provider, vs. , Employer, and , Insurer 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 PAYMENT OF ADDITIONAL REIMBURSEMENT OF MEDICAL FEES filed herein by on the FOLLOWING GROUNDS: (name of health care provider) In support of this request, the employer states that there is no genuine issue of fact necessitating an evidentiary hearing in regard to the APPLICATION FOR PAYMENT OF ADDITIONAL REIMBURSEMENT OF MEDICAL FEES, 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. DIVISION USE ONLY 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) Date Bar No. DATE STAMP Missouri Division of Workers' Compensation is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. WC-297 (01-14) AI Relay Missouri: 800-735-2966 www.FormsWorkflow.com