Free ANNUAL MEDICAL PAYMENT REPORT - Michigan

ANNUAL MEDICAL PAYMENT REPORT
Michigan Department of Energy, Labor & Economic Growth Workers' Compensation Agency Health Care Services Division PO Box 30016, Lansing, MI 48909

ANNUAL REPORTING PERIOD: 1/01/_____ to 12/31/_____ (Due by February 28th the Year Following the Reporting Period)

I.

CARRIER INFORMATION
NAIC or Self-Insured No.

Carrier Name (Insurance Co., Self-Insured, or Fund)

Address (number & street)

Telephone No. (include area code)

City, State, Zip Code

Carrier Contact Person and Email address

Service Co. Submitting Information for Self-Insured/Self-Administered

Service Co. Contact Person & Telephone No. (include area code)

Service Co./Self-Insured/Self-Administered Email Address

Service Co. Contact Person Email Address

II. ANNUAL MEDICAL PAYMENT REPORT Include data for payment of all medical expenditures. Do not include payments for the following: a. Indemnity payments b. Mileage reimbursement c. Vocational rehabilitation or medical case management expenses d. Independent medical examinations or legal expenses
CASE TYPE Medical Only Cases Medical Paid on Wage Loss Cases NUMBER OF CASES TOTAL DOLLARS SPENT FOR MEDICAL CARE $ $

Are you continuing to do business in Michigan? (Check appropriate box) If no, what is the termination date? ______________________________

Yes

No

By signing this form, I certify that the information included in this annual medical payment report and accompanying attachments, if any, is true, correct and complete to the best of my knowledge.
Authorized Signature Authorized Name and Email address Date

Alternate Contact Person

Alternate Email Address

Alternate's Telephone Number

DELEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-406 (Rev. 6/09)

Workers' Compensation Health Care Services Rules, part 14, R418.101401 Authority: Completion: Mandatory. Must be completed and submitted to the agency by 2/28 annually for the previous year. Failure to provide data shall prevent certification of the Carrier's Professional Penalty: Health Care Review Program pursuant to part 12, R418.101206