Agreement On The Propriety Of Services And Selection Of Practitioner
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Agreement On The Propriety Of Services And Selection Of Practitioner Form. This is a Maryland form and can be use in Adjudication Claims Workers Compensation.
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Tags: Agreement On The Propriety Of Services And Selection Of Practitioner, VR06, Maryland Workers Compensation, Adjudication Claims
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:
WCC Number:
Address:
The undersigned hereby agrees to the propriety of vocational rehabilitation services and the selection
of the above-named vocational rehabilitation practitioner.
Employer/Insurer Name
Signature
Telephone Number
Date
Claimant/Attorney Name
Signature
Telephone Number
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)
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