How to Complete the Missouri Division of Workers' Compensation Release of Lien Form

Purpose of the Release of Lien Form

The Release of Lien form lets a claimant or their attorney confirm that all medical providers, insurers, and other lienholders have been paid, allowing the Division of Workers' Compensation to close the case and issue any remaining benefits.

Key Information Required

Every field must be completed accurately to avoid delays. The form asks for:

• Claimant's full legal name and Social Security number
• Employer's name, address, and FEIN
• Case number assigned by the Missouri Division of Workers' Compensation
• Names and addresses of all medical providers, hospitals, and other lienholders
• Exact dollar amounts paid to each lienholder
• Date of final payment and signature of the claimant or authorized attorney

Step‑by‑Step Completion Guide

1. Gather Documentation

Collect final invoices, payment receipts, and any settlement agreements. Verify that each provider's account reflects a zero balance before proceeding.

2. Fill in Claimant and Employer Details

Enter the claimant's name exactly as it appears on the workers' comp claim. Use the employer's legal name and the Federal Employer Identification Number (FEIN) found on the employer's tax documents.

3. List Lienholders

For each medical provider, list the name, address, and the amount paid. If a provider has multiple invoices, sum the amounts and note the total. Include any secondary lienholders such as pharmacy benefit managers or sub‑contractors.

4. Calculate Total Paid

Sum all individual payments to arrive at the total amount released. This figure must match the total shown on the accompanying payment ledger.

5. Sign and Date

The claimant must sign in ink; an attorney's signature is acceptable if they hold a power of attorney. The date must reflect when the final payment was made.

Common Errors to Avoid

Missing or mismatched Social Security numbers, incorrect FEINs, and omitted lienholders are the most frequent reasons for rejection. Double‑check spelling, use consistent formatting, and verify that every dollar amount adds up.

Filing and Follow‑Up

Submit the completed form to the Division of Workers' Compensation office handling the case, either by certified mail or in person. Retain a copy for your records. After filing, the Division will review the form within 10‑15 business days; any discrepancies will be noted in a written notice, prompting a correction.

Comparison of Filing Options