APPLICATION FOR MEDIATION OR HEARING � FORM B Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency PO Box 30016, Lansing, MI 48909 I hereby certify that we have complied with Rules 1301 through 1305 and Parts 9 and 10 of the Workers' Compensation Health Care Services Rules Submitted on behalf of: EMPLOYEE IDENTIFICATION 1. Employee Name (Last, First, MI) Health Care Provider Insurance Company Self-Insured Employer 2. Social Security Number 3. Date of Birth 4. Date of Injury 5. Street Address 6. City 7. State 8. ZIP Code 9. County of Injury EMPLOYER IDENTIFICATION 10. Employer Name 11. Federal I.D. Number 12. Street Address 13. City 14. State 15. ZIP Code 16. Contact Person 17. Telephone Number CARRIER IDENTIFICATION 18. Carrier or Self-Insured Name 19. NAIC or Self-Insured Number 20. Street Address 21. City 22. State 23. ZIP Code 24. Claim Handler 25. Claim Number 26. Telephone Number HEALTH CARE PROVIDER IDENTIFICATION 27. Provider Name 28. License, Registration, or Certification Number 29. Street Address 30. City 31. State 32. ZIP Code 33. Date of Service Amount of Bill Date of 1 Billing st Date of 2 Billing nd Late Fee Requested Reason for Filing (see codes on reverse) 34. If the worker involved in this case is currently being denied treatment as a result of this dispute, check the box on the left and provide a description of the needed treatment that is being denied in the box on the back. If the carrier is currently paying for medical benefits pursuant to an order and this is a petition to stop such payment, check the box on the left and attach a copy of the order. 35. By signing this form, I certify that the information included on this form is true, correct and complete to the best of my knowledge. I understand that 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. 36. Applicant Name 37. Telephone Number 38. Applicant Email Address 39. Applicant Signature 40. Date 41. Name of Attorney (if applicable) 42. Attorney I.D. 43. Attorney Telephone Number 44. Attorney Signature WC-104B (Rev. 9/13) American LegalNet, Inc. www.FormsWorkFlow.com Reason for Filing Codes (last column in Line 33) A. B. C. D. E. F. G. H. I. No response to the bill Not paid in 30 days per R418.10116 (2) No carrier response to provider's request for reconsideration Incorrect payment, not resolved by provider's request for reconsideration Claim in litigation, medical services remain unpaid Carrier disputed utilization of medical services Carrier requests recovery of payment No report of injury on file with carrier Other Additional information regarding Reason for Filing: This form is only to be submitted in cases involving workers' compensation health care disputes between carriers (insurance companies, self-insured employers, or group funds) and health care providers. The completed application must be mailed to the Workers' Compensation Agency, PO Box 30016, Lansing, MI 48909, with a completed copy mailed to the carrier. There is no need to send additional documentation to have the teleconference scheduled. You must complete this form properly to avoid any delay in processing. All parties involved in this case will be served a copy of the Form 104B and a teleconference will be scheduled. You can obtain more information or forms by contacting the Workers' Compensation Agency at 1-888-396-5041. This application is provided in accordance with Part 13, R 418.101303 of the Workers' Compensation Health Care Services Rules. LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-104B (Rev. 9/13) American LegalNet, Inc. www.FormsWorkFlow.com