Provider's Report of Claim & Request for Medical Payment Form

Since 2002, health care providers have been afforded an avenue to notify workers’ compensation insurance carriers of an employee’s injury and potential claim, by submitting Provider's Report of Claim & Request for Medical Payment Form WC-117H directly to the carrier.  As a provider, please review the instructions below for completion and submission of this form to the carrier.

Instructions for Completion of Form WC-117H

  1. The injured employee should complete section one; the provider should complete section two, as indicated on the form.
  2. The name of the person on the employer's authorization form or telephone referral should be provided in the box titled "employer's representative authorizing treatment". A telephone number should be included on the form for future reference by the provider and carrier.
  3. The completed form should be retained in the patient's file for possible future submission to the carrier on the injured worker's behalf. This form should not be sent to the Agency.
  4. The provider should initially bill the carrier for their medical services without attaching the Form WC-117H.
  5. If the carrier rejects payment because there is no report of injury on file with the carrier, or if the carrier fails to respond to a medical bill within 30 days, the provider may then send the Form WC-117H to the carrier. Again, Copies of this form should not be sent to the Agency under any circumstances.

This form is available on the Agency website under the Forms section, or by using the links above.