Michigan Provider's Report of Claim & Request for Medical Payment is a form that is used by healthcare providers in the state of Michigan to bill for services rendered to patients. It is used to request reimbursement from the patient's insurance company for the cost of services provided. The form contains information about the patient, the healthcare provider, and the services provided, as well as a breakdown of the charges for the services rendered. There are two types of Michigan Provider's Report of Claim & Request for Medical Payment: the Original Claim and the Reimbursement Request. The Original Claim form is used to submit a claim for payment and is typically sent to the patient's insurance company. The Reimbursement Request form is used by the provider to request payment from the patient's insurance company for services already rendered. Both forms require detailed information about the patient, the provider, and the services rendered, as well as a breakdown of the charges.