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Agreement On The Propriety Of Services And Selection Of Practitioner VR06 - Maryland
| Agreement On The Propriety Of Services And Selection Of Practitioner Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS' COMPENSATION COMMISSION AGREEMENT ON THE PROPRIETY OF SERVICES AND SELECTION OF PRACTITIONER INSTRUCTIONS: Pursuant to COMAR 14.09.05.09 this form must be submitted to the Workers' Compensation Commission and a copy sent to the selected vocational rehabilitation practitioner. WCC CLAIM NUMBER: CLAIMANT: EMPLOYER: INSURER: Agreed Upon Vocational Rehabilitation Practitioner: Practitioner Name: Address: WCC Number: The undersigned hereby agrees to the propriety of vocational rehabilitation services and the selection of the above-named vocational rehabilitation practitioner. Employer/Insurer Name Telephone Number Signature Date Claimant/Attorney Name Telephone Number Signature Date NOTICE Pursuant to COMAR 14.09.05.09, the practitioner may not contact the above claimant or initiate vocational rehabilitation services until the practitioner has received a copy of this notice. CERTIFICATION OF SERVICE I hereby certify that on this day of , 20 , I mailed, postage prepaid, a copy of this AGREEMENT and any attached documentation to all parties and their attorneys. Signature Telephone 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us WCC Form VR06 (03.10) American LegalNet, Inc. www.FormsWorkFlow.com
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