Form Wc-117h - State Of Michigan Provider'S Report Of Claim & Request For Medical Payment
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1PROVIDER’S REPORT OF CLAIM
REQUEST FOR MEDICAL PAYMENT
&
Michigan Department of Licensing and Regulatory Affairs
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?
Yes
No
Was injury reported to your employer?
Yes
No
If yes, date of return
If yes, date reported
Employee signature
Date of this report
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. 1/12)
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Parent category: Legal