Request By A Health Care Provider For Case Status Information {WC-194}

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS REQUEST BY A HEALTH CARE PROVIDER FOR CASE STATUS INFORMATION TO FILE A MEDICAL FEE DISPUTE APPLICATION 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 Note: If you file an "Application for Direct Payment" or an "Application for Payment of Additional Reimbursement of Medical Fees," please return this completed form with your application. This form must be completed in its entirety for the Division to evaluate your request. You should complete the Employer and Insurer information that you have on file prior to submitting this form. Please state "unknown" if you are unable to complete any required field. Health Care Provider Information Name & Address Contact Person Name Telephone No. Employee Information Name Social Security No. Date of Accident/Occupational Disease Injured Body Part(s) Date Service Provided Employer Information Name Address Insurer Information Name Address I am requesting the Division to provide the following information (please check all that apply) Injury No. Insurance Carrier Status Update a. Report of Injury has been filed with the Division b. Claim for Compensation has been filed with the Division c. Date the case was Settled d. Date the case was Dismissed Name and Address of Claimant's Attorney Yes Yes No No Name and Address of Employer/Insurer Attorney Please return completed form with a self-addressed stamped envelope to: Missouri Division of Workers' Compensation Attn: Medical Fee Dispute Unit P.O. Box 58 Jefferson City, MO 65102-0058 DIVISION USE ONLY 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-194 (07-13) AI American LegalNet, Inc. www.FormsWorkFlow.com