PROVIDER'S REPORT OF CLAIM & REQUEST FOR MEDICAL PAYMENT Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency Social Security Number 1. EMPLOYEE TO COMPLETE THIS SECTION Employee Name (Last, First, MI) 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. 1/12) American LegalNet, Inc. www.FormsWorkFlow.com