WORKERS' COMPENSATION COMMISSION CONTROVERSION OF MEDICAL CLAIM INSTRUCTIONS: This form is to be used ONLY for the purpose of controverting an Order Nisi and MAY NOT be used to raise any other issue. If other issues exist WCC Form H24R "Issues" must be filed with the Commission. Pursuant to COMAR 14.09.08.06G a hearing will be scheduled on this controversion in the normal course. WCC Claim Number: Claimant Name: Employer: Insurer: The Employer/Insurer Healthcare Provider hereby controverts t h e O rd e r N i s i i s s u ed i n t hi s ca se fo r p rof ession al service s p ro vid ed b y: Healthcare Provider Street Suite/Additional Address City State ZIP Code A F i n al O rd er sho ul d n ot b e issu ed fo r th e fo llowing re aso n(s) : CERTIFICATION OF SERVICE I hereby certify that on this day of , , I mailed, postage prepaid, a copy of the foregoing "Controversion of Medical Claim" to all parties and their attorneys. Name of Party Raising Issues Telephone Number Signature 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us MD WCC Form H-32 3/2014 American LegalNet, Inc. www.FormsWorkFlow.com