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Publications and Forms

Application for Certification - Safety Consultant/Safety Engineer (WSP-10)

A form application for certification for a safety consultant or safety engineer.

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 Joint Account (MODES-2241)

An employer application for a joint account.

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.

Assignment and Escrow Agreement (MODES-4251)

Some employers ("lessors") lease employees to clients. Unless the lessor provides a financial guarantee, such as posting securities, to ensure prompt payment of unemployment liabilities: (1) the lessor must file a separate Quarterly Contribution and Wage Report for the employees leased to each client; and (2) the client is jointly liable for the contributions otherwise due on the workers it leases from the lessor. MODES-4251 must be used for the posting of securities.

Authorization For Release Of Confidential Information (MODES-4354-3)

A form to authorize the release of confidential information for irrevocable letter of credit.

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.