ANNUAL MEDICAL PAYMENT REPORT Michigan Department of Labor & Economic Growth Workers' Compensation Agency Health Care Services Division PO Box 30016, Lansing, Michigan 48909 Due by February 28th Year Ending 200_ I. CARRIER INFORMATION Carrier Name Carrier NAIC No., Self-Insured No., or FEIN No Carrier Address (Street) Carrier Telephone No. (Include area code) Carrier City, State, ZIP Code Carrier Contact Person Service company or Review Company submitting the Information Contact Person and Telephone No. (Include area code) 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 Wage Loss Number of Cases Total Dollars Spent for Medical Care $ $ 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 (In ink) Authorized Name (Typed) Date Authority: Workers' Compensation Health Care Services Rules, part 14, R 418.101401 Completion: Mandatory. Must completed and submitted to the bureau by 2/28 annually for the previous year. Penalty: Failure to provide data shall prevent certification of the Carrier's Professional Health Care Review Program pursuant to Part 12, R 418.101206 WC-406 (REV. 1-04) American LegalNet, Inc. www.USCourtForms.com