PROVIDER’S REPORT OF CLAIM & REQUEST FOR MEDICAL PAYMENT Forms
| Form Name | PROVIDER’S REPORT OF CLAIM & REQUEST FOR MEDICAL PAYMENT |
| Form # | WC-117H |
| Form Revision | (Rev. 8/19) |
| Category | Forms » Medical/Health |
| Downloads | |
| Form State | Michigan |
| Language | English |
| State Description | n/a |
| Claimwire Description | n/a |