Michigan > Workers Comp
Application For Mediation Or Hearing-Form B WC-104B - Michigan
| Application For Mediation Or Hearing-Form B Form. This is a Michigan form and can be used in Workers Comp . |
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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) 5. Street Address Health Care Provider Insurance Company 2. Social Security Number Self-Insured Employer 3. Date of Birth 8. ZIP Code 4. Date of Injury 9. County of Injury 6. City 7. State EMPLOYER IDENTIFICATION 10. Employer Name 12. Street Address 16. Contact Person 13. City 11. Federal I.D. Number 14. State 17. Telephone Number 15. ZIP Code CARRIER IDENTIFICATION 18. Carrier or Self-Insured Name 20. Street Address 24. Claim Handler 21. City 25. Claim Number 19. NAIC or Self-Insured Number 22. State 26. Telephone Number 23. ZIP Code HEALTH CARE PROVIDER IDENTIFICATION 27. Provider Name 29. Street Address 30. City 28. License, Registration, or Certification Number 31. State 32. ZIP Code Reason for Filing (see codes on reverse) 33. Date of Service Amount of Bill Date of 1st Billing Date of 2nd Billing Late Fee Requested 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. Applicant Signature 38. Applicant Telephone Number 39. Date 40. Name of Attorney (if applicable) 41. Attorney I.D. 42. Attorney Signature WC-104B (Rev. 1/12) Front 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. 1/12) Back American LegalNet, Inc. www.FormsWorkFlow.com
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