Answer To Application For Direct Payment {WC-199}

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS ANSWER TO APPLICATION FOR DIRECT PAYMENT Original Amended 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 W.C. Injury Number Medical Fee Dispute No. Venue NOTE: No Answer to Application for Direct Payment is required. However, if the Employer/Insurer would like to file an Answer this form should be utilized. 1. Health Care Provider Name Mailing Address City State ZIP Code 2. Employee (Patient's) Name Mailing Address City State ZIP Code 3. Name of Employer Mailing Address City State ZIP Code 4. Name of Insurer/Third Party Administrator Mailing Address City State ZIP Code 5. Name all authorized providers of medical aid: 6. Date of Accident/Occupational Disease 7. All of the statements or allegations in the "Application for Direct Payment" are admitted except the following: Please describe below each statement or allegation in the "Application for Direct Payment" that is being disputed, the reason why it is being disputed and the facts thereto. Please list all affirmative defenses. If needed, attach sheet with additional information. 8. Employer's Signature Date 9. Insurer's Signature Date 10. Attorney Signature Attorney Name (Type or Print) Bar No. Attorney E-mail Address Attorney Mailing Address City State ZIP Code Attorney Phone No. Attorney Fax No. CERTIFICATE OF SERVICE I, the undersigned, certify that a true and accurate copy of this Answer to Application for Direct Payment has been mailed or hand delivered to all attorneys and/or all parties of record this day of , 20 . Attorney's Signature Attorney's Name (Printed) Address (if different than above) Date Bar No. DIVISION USE ONLY DATE STAMP WC-199 (03-12) AI www.FormsWorkflow.com