Form WC-202 "Health Care Provider's Response to Request for Award on Undisputed Facts in Regard to Application for Direct Payment" - Missouri

What Is Form WC-202?

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 September 1, 2011;
  • 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-202 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-202 "Health Care Provider's Response to Request for Award on Undisputed Facts in Regard to Application for Direct Payment" - Missouri

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
HEALTH CARE PROVIDER’S RESPONSE TO
3315 West Truman Blvd.
P.O. Box 58
REQUEST FOR AWARD ON UNDISPUTED FACTS IN
Jefferson City, MO 65102-0058
REGARD TO APPLICATION FOR DIRECT PAYMENT
Pursuant to 8 CSR 50-2.030(2)(I)(b) the health care provider shall file its response to the award on undisputed facts within thirty days.
,
)
Health Care Provider,
)
Medical Fee Dispute No:
-
)
vs.
)
Injury No.:
-
)
,
)
Employee (Patient):
Employer,
)
)
Date of Accident/
and
)
Occupational Disease:
)
,
)
Insurer
)
RESPONSE TO REQUEST FOR AWARD ON UNDISPUTED FACTS
Health Care Provider
herein, for its response to the
(name of health care provider)
REQUEST FOR AWARD ON UNDISPUTED FACTS filed by Employer/Insurer states as follows (attach additional sheets, if
necessary):
In support of its statements, Health Care Provider attaches the following exhibits (attach additional sheets, if necessary):
Please identify each exhibit by numbers “1,” “2,” etc. and by general description of the document.
Health Care Provider Signature & Date
Health Care Provider Address & Telephone No.
Health Care Provider’s Attorney Signature & Date
Attorney’s Address & Telephone No.
(if applicable)
DIVISION USE ONLY
CERTIFICATE OF SERVICE
I, the undersigned, certify that a true and accurate copy of this Response to 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
Date
Attorney’s Name (Printed)
Bar No.
Address (if different than above)
DATE STAMP
WC-202 (09-11) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
HEALTH CARE PROVIDER’S RESPONSE TO
3315 West Truman Blvd.
P.O. Box 58
REQUEST FOR AWARD ON UNDISPUTED FACTS IN
Jefferson City, MO 65102-0058
REGARD TO APPLICATION FOR DIRECT PAYMENT
Pursuant to 8 CSR 50-2.030(2)(I)(b) the health care provider shall file its response to the award on undisputed facts within thirty days.
,
)
Health Care Provider,
)
Medical Fee Dispute No:
-
)
vs.
)
Injury No.:
-
)
,
)
Employee (Patient):
Employer,
)
)
Date of Accident/
and
)
Occupational Disease:
)
,
)
Insurer
)
RESPONSE TO REQUEST FOR AWARD ON UNDISPUTED FACTS
Health Care Provider
herein, for its response to the
(name of health care provider)
REQUEST FOR AWARD ON UNDISPUTED FACTS filed by Employer/Insurer states as follows (attach additional sheets, if
necessary):
In support of its statements, Health Care Provider attaches the following exhibits (attach additional sheets, if necessary):
Please identify each exhibit by numbers “1,” “2,” etc. and by general description of the document.
Health Care Provider Signature & Date
Health Care Provider Address & Telephone No.
Health Care Provider’s Attorney Signature & Date
Attorney’s Address & Telephone No.
(if applicable)
DIVISION USE ONLY
CERTIFICATE OF SERVICE
I, the undersigned, certify that a true and accurate copy of this Response to 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
Date
Attorney’s Name (Printed)
Bar No.
Address (if different than above)
DATE STAMP
WC-202 (09-11) AI