Form WC-201 "Request for Award on Undisputed Facts in Regard to Application for Direct Payment" - Missouri

What Is Form WC-201?

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-201 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 WC-201 "Request for Award on Undisputed Facts in Regard to Application for Direct Payment" - Missouri

781 times
Rate (4.5 / 5) 55 votes
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
3315 West Truman Blvd.
REQUEST FOR AWARD ON UNDISPUTED
P.O. Box 58
FACTS IN REGARD TO APPLICATION FOR
Jefferson City, MO 65102-0058
DIRECT PAYMENT
,
)
Health Care Provider,
)
Medical Fee Dispute No:
-
)
vs.
)
Injury No.:
-
)
,
)
Employee (Patient):
Employer,
)
)
Date of Accident/
and
)
Occupational Disease:
)
,
)
Insurer
)
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 DIRECT PAYMENT filed herein by
(name of health care provider)
on the ground that the health care services for which direct payment is being sought were not authorized by Employer or its Insurer. In
support of this request, Employer states that there is no genuine issue of fact necessitating an evidentiary hearing in regard to the
APPLICATION FOR DIRECT PAYMENT, 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 Address & Telephone No.
Employer/Insurer Attorney’s Signature & Date
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
Date
Attorney’s Name (Printed)
Bar No.
Address (if different than above)
DATE STAMP
WC-201 (09-11) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
3315 West Truman Blvd.
REQUEST FOR AWARD ON UNDISPUTED
P.O. Box 58
FACTS IN REGARD TO APPLICATION FOR
Jefferson City, MO 65102-0058
DIRECT PAYMENT
,
)
Health Care Provider,
)
Medical Fee Dispute No:
-
)
vs.
)
Injury No.:
-
)
,
)
Employee (Patient):
Employer,
)
)
Date of Accident/
and
)
Occupational Disease:
)
,
)
Insurer
)
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 DIRECT PAYMENT filed herein by
(name of health care provider)
on the ground that the health care services for which direct payment is being sought were not authorized by Employer or its Insurer. In
support of this request, Employer states that there is no genuine issue of fact necessitating an evidentiary hearing in regard to the
APPLICATION FOR DIRECT PAYMENT, 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 Address & Telephone No.
Employer/Insurer Attorney’s Signature & Date
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
Date
Attorney’s Name (Printed)
Bar No.
Address (if different than above)
DATE STAMP
WC-201 (09-11) AI