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

Form WC-201 or the "Request For Award On Undisputed Facts In Regard To Application For Direct Payment" is a form issued by the Missouri Department of Labor and Industrial Relations.

The form was last revised in September 1, 2011 and is available for digital filing. Download an up-to-date Form WC-201 in PDF-format down below or look it up on the Missouri Department of Labor and Industrial Relations Forms website.

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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

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

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