WCA - WC-104B (6/09) - Health Care Services Application for Mediation or Hearing (fill-in form)

Skip Navigation

Printer Friendly Text Only Version

WC-104B (1/12) - Health Care Services Application for Mediation or Hearing (fill-in form)

The WC-104B is a two-sided form that must be printed front-to-back on one sheet of orange paper. Forms not submitted properly will be returned.

To request a form to be sent in the mail, please call toll-free 1-888-396-5041 or email wcinfo@michigan.gov.


	Related Content
•	WC-40 (1/12) - Request for Compliance Hearing (fill-in form)
•	WC-104A (2/12) - Application for Mediation or Hearing (fill-in form)
•	WC-104C (2/12) - Defendant's Application for Mediation or Hearing (fill-in form)
•	WC-105A (3/09) Work History, Work Qualifications & Training Disclosure Questionnaire (fill-in form)
•	WC-105B (3/09) Employer Disclosure Questionnaire (fill-in form)
•	WC-113 (4/09) - Redemption Order (fill-in form)
•	WC-113A (3/09) - Multiple Carrier Redemption Form (fill-in form)
•	WC-115 (5/05) - Voluntary Payment Form (fill-in form)
•	WC-119 (8/05) - Affidavit in Support of Redemption (settlement) Agreement (fill-in form)
•	WC-200 (12/03) - Opinion/Order (fill-in form)
•	WC-251 (8/05) - Carrier's Response (fill-in form)
•	WC-262 (4/05) - Claim/Cross-Claim for Review (fill-in form)
•	WC-508 (1/12) - Subpoena for Production of Records (and/or) Witness Subpoena (fill-in form)
•	WC-544 (7-05) - Worker's Settlement Statement (fill-in form)
•	WC-556 (5/05) - Agreement to Redeem Liability (fill-in form)
•	WC-117H (1/12) Provider's Report of Claim & Request for Medical Payment
•	WC-406 (1/12) Annual Medical Payment Report
•	WC-590 (1/12) Application for Certification of a Carrier's Professional Health Care Review Program
•	WC-739 (2/12) Carrier's Explanation of Benefits