Get the free Form WC-117H. Provider's Report of Claim & Request for Medical Payment

PROVIDERS REPORT OF CLAIM & REQUEST FOR MEDICAL PAYMENT Michigan Department of Labor and Economic Opportunity Workers Disability Compensation Agency1. EMPLOYEE TO COMPLETE THIS SECTION Employee Name

How to fill out form wc-117h providers report

How to fill out form wc-117h providers report

1. To fill out form wc-117h providers report, follow these steps:
2. Start by entering your personal information in the designated sections of the form, such as your name, address, and contact details.
3. Provide the necessary details about the injured worker, including their name, SSN, date of birth, and the date of injury.
4. Specify the type of service provided by selecting the appropriate service code and description.
5. Indicate the duration of service and the total charge for each service provided.
6. If applicable, include any specific diagnosis or procedure codes related to the service provided.
7. Provide the necessary information about the provider, including their name, Tax ID, and NPI numbers.
8. Attach any supporting documentation, such as medical records or invoices, to the form if required.
9. Review the completed form for accuracy and completeness before submitting it.
10. Submit the filled-out form to the relevant authority or organization as instructed.

Who needs form wc-117h providers report?

1. Form wc-117h providers report is needed by healthcare providers or medical service providers who have provided services to injured workers.
2. This form is used to report the details of the services provided and the associated charges to the relevant authorities or insurance organizations.

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What is form wc-117h providers report?

Form WC-117H providers report is a form used to report medical treatment provided to injured workers in workers' compensation cases.

Who is required to file form wc-117h providers report?

Healthcare providers who have provided medical treatment to injured workers in workers' compensation cases are required to file form WC-117H providers report.

How to fill out form wc-117h providers report?

Form WC-117H providers report should be filled out with accurate information regarding the medical treatment provided to the injured worker, including dates of service, treatments provided, and charges.

What is the purpose of form wc-117h providers report?

The purpose of form WC-117H providers report is to document and report the medical treatment provided to injured workers in workers' compensation cases.

What information must be reported on form wc-117h providers report?

Information that must be reported on form WC-117H providers report includes dates of service, treatments provided, charges, and any other relevant medical information.