Free Controversion of Medical Claim H24M - Maryland

WORKERS' COMPENSATION COMMISSION
10 East Baltimore Street q Baltimore, Maryland 21202-1641
410-864-5100 q Email: [email protected] qWeb: http://www.wcc.state.md.us

WCC CLAIM NO.: CLAIMANT: EMPLOYER: INSURER:
RESERVED FOR AGENCY USE

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

SUITE /ADDITIONAL ADDRESS

CITY

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)

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