WORKERS' COMPENSATION COMMISSION INSURER'S TERMINATION OF MEDICAL BENEFITS Pursuant to COMAR 14.09.06.04C, this form must be sent to the claimant. A copy must also be sent to the claimant's treating physician or health care provider, the Workers' Compensation Commission and the claimant's attorney. WCC Claim Number: Claimant: Employer: Insurer: This is to advise that the insurer/employer will terminate payment for medical benefits . under the above captioned claim effective: The claimant has the right to request a hearing before the Workers' Compensation Commission on the issue of this termination of medical benefits. Health Care Provider: Service or treatment being terminated: Health Care Provider: Service or treatment being terminated: INSURER CERTIFICATION OF SERVICE I hereby certify that on the day of , 20 , a copy of this notice was sent to the Claimant, his/her counsel, the Maryland Workers' Compensation Commission and to the above named Health Care Provider(s). Signature: ___________________________________ Printed Name: Telephone Number: Date: 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 C-10 (1/2016) American LegalNet, Inc. www.FormsWorkFlow.com