Fill and Sign the Michigan Annual Report Form

Year ending 200                                                                                                      Due by February 28th ANNUAL MEDICAL PAYMENT REPORT Michigan Department of Consumer& Industry Services Bureau of Workers' Disability Compensation Health Care Services Division PO Box 30016, Lansing, Michigan 48909I. CARRIER INFORMATION Carrier Name Carrier NAIC No., Self-insured No., or FEIN No Carrier Address (Street) Carrier Telephone No. (include area code) Carrier City, State, ZIP Code Carrier Contact Person Service company or Review Company submitting the Information Contact Person and Telephone No. (include area code) II. ANNUAL MEDICAL PAYMENT REPORT Include data for payment of all medical expenditures. Do not include payments for the following: a. Indemnity payments b. Mileage reimbursement c. Vocational rehabilitation or medical case management expenses d. Independent medical examinations or legal expenses Case Type Number of Cases Total Dollars Spent for Medical Care Medical Only $ Wage Loss $ By signing this form, I certify that the information included in this annual medical payment report and accompanying attachments, if any, is true, correct and complete to the best of my knowledge. Authorized Signature (in ink) Authorized Name (Typed) Date Authority: Workers Compensation Health Care Services Rules, part 14, R 418.101401Completion: Mandatory. Must completed and submitted to the bureau by 2.28 annually for the previous year.Penalty:418.101206 Failure to provide data shall prevent certification of the Carrier's Professional Health Care Review Program pursuant to Part 12, R BWC-406 (REV. 04-00) (Formerly MDL-406)