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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.

 Click here for WC-104B 

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