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Go to Page 2 Print Reset 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 Health Care Provider Insurance Company Self-Insured Employer EMPLOYEE IDENTIFICATION 1.
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How to fill out an application for mediation:

01
Start by gathering all necessary information such as your personal details, the details of the other party involved, and any relevant dates or incidents.
02
Research the specific requirements for the mediation program or organization you are applying to. Determine if there are any specific forms or formats that need to be followed.
03
Fill out the application form carefully, ensuring all information is accurate and complete. Pay attention to any specific instructions or fields that need to be addressed.
04
If required, attach any supporting documents or evidence that may be relevant to your case. Make sure to organize and label these documents clearly.
05
Review the completed application form and supporting documents to check for any errors or omissions. Make any necessary corrections before submitting.
06
Follow the submission instructions provided by the mediation program or organization. This may involve delivering the application form in person, mailing it, or submitting it online.

Who needs an application for mediation:

01
Individuals who wish to resolve a dispute through mediation rather than court litigation.
02
Parties involved in a legal dispute looking for an alternative means of resolving their issues.
03
Organizations or businesses seeking to address conflicts or disagreements with other parties in a structured and facilitated manner.
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An application for mediation is a formal request submitted to a mediation center or institution, seeking assistance in resolving a dispute or conflict through mediation.
Any party involved in a dispute or conflict can file an application for mediation. This includes individuals, organizations, or businesses.
The application for mediation can usually be filled out online or obtained directly from the mediation center or institution. It typically requires providing contact information, a brief description of the dispute, and any relevant documents or evidence.
The purpose of the application for mediation is to formally request the assistance of a neutral mediator or mediation center to facilitate the resolution of a dispute or conflict outside of traditional legal proceedings.
The information required on an application for mediation typically includes the names and contact information of the parties involved, a description of the dispute or conflict, and any relevant documents or evidence.
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Related Links

WCA - Forms - State of Michigan
Worker's Compensation Agency - Forms. ... WC-104B (9/13) - Health Care Services Application for Mediation or Hearing (fill-in form) PDF icon; WC-117H (1/ 12) ...
Application for Mediation or Hearing
The completed application must be mailed to the Workers' Disability Compensation. Agency at the above address. Please send only one copy. If you require more ...
APPLICATION FOR MEDIATION OR HEARING – FORM B
This form is only to be submitted in cases involving workers' compensation health care disputes between carriers (insurance companies, self-insured employers, ...

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