Free Application for Reimbursement from the Medical Benefits Fund (Form BWC-271) - Michigan

APPLICATION FOR REIMBURSEMENT FROM THE MEDICAL BENEFITS FUND
Michigan Department of Consumer & Industry Services Bureau of Workers' & Unemployment Compensation P O Box 30016, Lansing, MI 48909
Authority: Workers' Disability Compensation Act 418.862(2). Completion of this form is voluntary.

Type or print clearly. Incomplete applications shall be returned.
Employee Name (Last, First, MI) Social Security Number

Address (Street Number and Name)

Date of Injury

Date of Birth

City

State

Zip Code

Employer Name

Insurance Carrier or Service Company

Address (Street Number and Name)

Address (Street Number and Name)

City

State

Zip Code

City

State

Zip Code

Federal ID Number

NAIC or Self-Insurance Number

Is there a health carrier covering this employee? If yes, please indicate the name of that carrier :

Yes

No

Please state the reason these bills have not been submitted to the health carrier for payment:

Period covered by this request
FROM Month Day Year Month THROUGH Day Year

A COPY OF THE MAGISTRATE'S ORDER AND ALL SUBSEQUENT APPELLATE ORDERS MUST ACCOMPANY THIS REQUEST.

Total Reimbursement Amount Requested

$

A COPY OF ALL ORIGINAL INVOICES (INCLUDING DATE OF SERVICE, NAME OF THE HEALTH CARE PROVIDER AND DIAGNOSIS) AND PROOF OF PAYMENT SHOWING AMOUNT AND DATE PAID MUST BE ATTACHED TO THIS REQUEST.

Before you sign this request for reimbursement, please be sure all attachments are included and the form is complete.
Name of Authorized Representative (Please print) Title Date

Signature of Authorized Representative

Telephone Number (Include area code)

BWC-271 (2-98)

Internet Form

The Department of Consumer & Industry Services will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.