PROVIDER'S REQUEST FOR RECONSIDERATION Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency Health Care Services PO Box 30016, Lansing, MI 48909 Provider Name Employee Name Address Street Address City State ZIP Code City State ZIP Code Social Security/FEIN Number* Social Security Number* Patient Account Number Date of Bill Date of Injury Carrier Name Telephone Number Address City State ZIP Code Employer Name Claim Number Date(s) of Service Charge Payment Requested Amount $ Reasons for Reconsideration (detailed statement) $ $ Documents Attached: WC-739 Contact Person Requested Report Office Notes Telephone Number Bill Date *Protected information to be used for identification purposes. LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-750 (Rev. 2/13) American LegalNet, Inc. www.FormsWorkFlow.com