WORKERS’ COMPENSATION COMMISSION 10 East Baltimore Street q Baltimore, Maryland 21202-1641 410-864-5100 q Email: info@wcc.state.md.us qWeb: http://www.wcc.state.md.us WCC CLAIM NO.: RESERVED FOR AGENCY USE CLAIMANT: EMPLOYER: INSURER: CONTROVERSION OF MEDICAL CLAIM The above-named Employer or Insurer hereby controverts the Order Nisi issued in this case for Professional services provided by HEALTH CARE PROVIDER STREET CITY SUITE /ADDITIONAL ADDRESS STATE ZIP CODE Reason for controversion: A Final Order should not be issued due to facts that are in dispute between the parties. A hearing is requested to resolve this dispute. The undersigned certifies that a copy of this form has been mailed to the above-named Health Care Provider and other parties as appropriate. To resolve the above issue, the estimated time required for hearing will be . The number of witnesses to be presented is (if none, so state). I certify that a copy of the above issues have been served on all parties listed above by mailing a copy of this form to the address shown above, this day of , . THIS FORM IS NOT BE USED TO RAISE ANY OTHER ISSUES. USE WCC Issues FORM H24R ___________________________ Signature of Party Raising Issues Telephone Number WCC H-24M (rev 01/28/2008) American LegalNet, Inc. www.FormsWorkflow.com