Form WC-MD-01 "Application for Direct Payment" - Missouri

What Is Form WC-MD-01?

This is a legal form that was released by the Missouri Department of Labor and Industrial Relations - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2012;
  • The latest edition provided by the Missouri Department of Labor and Industrial Relations;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form WC-MD-01 by clicking the link below or browse more documents and templates provided by the Missouri Department of Labor and Industrial Relations.

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Download Form WC-MD-01 "Application for Direct Payment" - Missouri

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
3315 West Truman Blvd., P.O. Box 58
Jefferson City, MO 65102-0058
APPLICATION FOR DIRECT PAYMENT
W.C. Injury Number
Please check the appropriate box.
Authorization potentially in dispute
Medical Fee Dispute No.
Authorization has been provided
Original
Amended
Use this form only if you are a hospital, physician or other health care provider that has provided services to an employee, which have been
authorized in advance by the employer or insurer or where the authorization is potentially in dispute.
Please note that pursuant to § 287.140.13 (6) RSMo, the services provided must relate to a work-related injury under the workers’
compensation law.
1. Health Care Provider Name
Address (Street, City & County)
State
ZIP Code
Telephone No.
2. Employee (Patient’s) Name
Address (Street, City & County)
State
ZIP Code
Date of Accident/Occupational Disease
Social Security No.
3. Name of Employer
Address (Street, City & County)
State
ZIP Code
Telephone No.
4. Name of Insurer/Third Party
Address (Street, City & County)
State
ZIP Code
Telephone No.
Administrator
5.
Brief Description of Disputed
Date Services
Name and Title of Person
Date Authorization
Amount
Amount
Services Rendered
Provided
Who Authorized Services
was Given
Billed
Claimed
A.
$
$
B.
$
$
C.
$
$
D.
$
$
E.
$
$
Total Amount Claimed $
(If needed, attach sheet with additional information.)
6. Signature of Health Care Provider*
Attorney Address
Attorney Telephone No.
7. Health Care Provider’s Attorney Signature & Date*
Bar No.
Attorney Fax No.
Attorney E-mail Address
DIVISION USE ONLY
CERTIFICATE OF SERVICE
I, the undersigned, certify that a true and accurate copy of this 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)
* Please be advised that corporations and limited liability companies appearing before the Division
must be represented by an attorney licensed in the State of Missouri. See Reed v. Labor and Ind.
Rel. Commn., 789 S.W.2d 19, 20 (Mo. banc 1990).
* If the Health Care Provider is a corporation or a LLC, and this Application is not signed by an
attorney, this Application will be rejected.
DATE STAMP
WC-MD-01 (03-12) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
3315 West Truman Blvd., P.O. Box 58
Jefferson City, MO 65102-0058
APPLICATION FOR DIRECT PAYMENT
W.C. Injury Number
Please check the appropriate box.
Authorization potentially in dispute
Medical Fee Dispute No.
Authorization has been provided
Original
Amended
Use this form only if you are a hospital, physician or other health care provider that has provided services to an employee, which have been
authorized in advance by the employer or insurer or where the authorization is potentially in dispute.
Please note that pursuant to § 287.140.13 (6) RSMo, the services provided must relate to a work-related injury under the workers’
compensation law.
1. Health Care Provider Name
Address (Street, City & County)
State
ZIP Code
Telephone No.
2. Employee (Patient’s) Name
Address (Street, City & County)
State
ZIP Code
Date of Accident/Occupational Disease
Social Security No.
3. Name of Employer
Address (Street, City & County)
State
ZIP Code
Telephone No.
4. Name of Insurer/Third Party
Address (Street, City & County)
State
ZIP Code
Telephone No.
Administrator
5.
Brief Description of Disputed
Date Services
Name and Title of Person
Date Authorization
Amount
Amount
Services Rendered
Provided
Who Authorized Services
was Given
Billed
Claimed
A.
$
$
B.
$
$
C.
$
$
D.
$
$
E.
$
$
Total Amount Claimed $
(If needed, attach sheet with additional information.)
6. Signature of Health Care Provider*
Attorney Address
Attorney Telephone No.
7. Health Care Provider’s Attorney Signature & Date*
Bar No.
Attorney Fax No.
Attorney E-mail Address
DIVISION USE ONLY
CERTIFICATE OF SERVICE
I, the undersigned, certify that a true and accurate copy of this 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)
* Please be advised that corporations and limited liability companies appearing before the Division
must be represented by an attorney licensed in the State of Missouri. See Reed v. Labor and Ind.
Rel. Commn., 789 S.W.2d 19, 20 (Mo. banc 1990).
* If the Health Care Provider is a corporation or a LLC, and this Application is not signed by an
attorney, this Application will be rejected.
DATE STAMP
WC-MD-01 (03-12) AI