Form WCR-8 "Request for Certification" - Missouri

What Is Form WCR-8?

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 October 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;
  • Fill out the form in our online filing application.

Download a fillable version of Form WCR-8 by clicking the link below or browse more documents and templates provided by the Missouri Department of Labor and Industrial Relations.

ADVERTISEMENT
ADVERTISEMENT

Download Form WCR-8 "Request for Certification" - Missouri

646 times
Rate (4.6 / 5) 32 votes
3315 West Truman Blvd.
P.O. Box 58
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
Jefferson City, MO 65102-0058
REQUEST FOR CERTIFICATION
573-751-4231
www.labor.mo.gov/DWC
Completion of this form indicates that the rehabilitation provider is interested in being contacted by the Division regarding
certification.
General Information:
Facility Name:
Address:
**** For multi-site facilities, please attach a list of all locations.
Contact Person:
Phone:
Fax:
E-mail:
Medical Director:
Years of Experience:
Date Facility Established:
Type of Facility:
Inpatient
Outpatient
List date of latest certification (if applicable):
JCAHO
CARF
Medicare
Other (specify)
No
If “Yes,” please provide date:
Has facility ever been certified by the Division?
Yes
What percentage of your client base is workers’ compensation?
Signature of person completing form
Title
Date
Return completed form to:
Fax: 573-522-1623
Mail:
Attn: Physical Rehabilitation
Missouri Division of Workers’ Compensation
Phone: 573-526-3876
P. O. Box 58
Jefferson City, MO 65102-0058
WCR-8 (10-11) AI
3315 West Truman Blvd.
P.O. Box 58
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
Jefferson City, MO 65102-0058
REQUEST FOR CERTIFICATION
573-751-4231
www.labor.mo.gov/DWC
Completion of this form indicates that the rehabilitation provider is interested in being contacted by the Division regarding
certification.
General Information:
Facility Name:
Address:
**** For multi-site facilities, please attach a list of all locations.
Contact Person:
Phone:
Fax:
E-mail:
Medical Director:
Years of Experience:
Date Facility Established:
Type of Facility:
Inpatient
Outpatient
List date of latest certification (if applicable):
JCAHO
CARF
Medicare
Other (specify)
No
If “Yes,” please provide date:
Has facility ever been certified by the Division?
Yes
What percentage of your client base is workers’ compensation?
Signature of person completing form
Title
Date
Return completed form to:
Fax: 573-522-1623
Mail:
Attn: Physical Rehabilitation
Missouri Division of Workers’ Compensation
Phone: 573-526-3876
P. O. Box 58
Jefferson City, MO 65102-0058
WCR-8 (10-11) AI