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Publications and Forms

Application for Direct Payment (WC-MD-01)

A form for use by a health care provider to apply for direct payment in regards to a workers' compensation medical fee dispute—if the health care provider believes that it can show that it was authorized to treat the employee but no payment has been made.

Application for Evidentiary Hearing (WC-MD-03)

A form for use by a health care provider, an employer or an insurer to request an evidentiary hearing in regards to a workers’ compensation medical fee dispute.

Application for Payment of Additional Reimbursement of Medical Fees (WC-MD-02)

A form for use by health care provider applying for payment of additional reimbursement of medical fees in a workers’ compensation medical fee dispute —if a partial payment has been made. (These are called “reasonableness” cases.)

Application for Tort Victims' Compensation (WCT-1)

An application for tort victims compensation.

Authorization to Inspect and/or Copy Medical Records (WC-43-AI)

An authorization form to inspect and/or copy medical records pertaining to a workers’ compensation case.

Authorization to Release Information (WC-126) and Instructions

This form allows a job applicant to grant a prospective employer access to the job applicant’s workers’ compensation record in Missouri.

Bi-Weekly Report on Physical Rehabilitation (WCR-5A)

A bi-weekly form to be completed by the healthcare provider to provide dates of physical rehabilitation treatments for an injured worker eligible for the physical rehabilitation benefit through the Second Injury Fund.

Dispute Management Process (WC-107)

A brochure outlining the voluntary dispute management process.

EDI File Matrix (WC-EDI-262)

EDI File Matrix, IAIBC release first report of injury.

EDI Missouri Data Dictionary (WC-EDI-219)

A dictionary of Missouri IAIABC data definitions.

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