Free Employee Name (Last, First, MI) - Michigan

PROVIDER'S REPORT OF CLAIM & REQUEST FOR MEDICAL PAYMENT
Michigan Department of Energy, Labor and Economic Growth Workers' Compensation Agency
1. EMPLOYEE TO COMPLETE THIS SECTION
Employee Name (Last, First, MI) Social Security Number

Employee Address

Date of Birth

City

State

Zip Code

Employee Telephone Number

Employer Name

Supervisor's Name

Employer Address

Employer Telephone Number

City

State

Zip Code

Describe the type of injury and explain how it happened.

Date of Injury

Last Day Worked

Have you gone back to work? If yes, date of return Employee signature

Yes

No

Was injury reported to your employer? If yes, date reported Date of this report

Yes

No

Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in criminal or civil prosecution, or both, and denial of benefits.

2. PROVIDER TO COMPLETE THIS SECTION
Health Care Provider Name Telephone Number

Address

Employer's representative authorizing treatment

City

State

Zip Code

Employer's representative's telephone number

Provider signature

Date

Carrier, Self-Insured or Group Fund Name

This form is to be submitted to the workers' compensation insurance carrier, self-insured employer or group fund.

DO NOT MAIL THIS FORM TO THE WORKERS' COMPENSATION AGENCY
WC-117H (Rev. 3/09)