Free MD WCC subpoena form - Maryland

WORKERS' COMPENSATION COMMISSION
10 EAST BALTIMORE STREET BALTIMORE, MARYLAND 21202-1641

SUBPOENA SUBPOENA DUCES TECUM SUBPOENA DUCES TECUM for Medical Record*
*Requesting Party must prepare & attach a Notice of Intent to Subpoena Medical Records pursuant to the AnnotatedCode of Maryland, Health General, Section 4-306(b).

Claim Number
Claimant versus and Employer Insurer
ATTENTION: THIS FORM IS NOT PRINTED IN DUPLICATE. IT IS THE RESPONSIBILITY OF THE PERSON ISSUING THE SUBPOENA TO MAKE DUPLICATE COPIES

TO:
Name Address

City

State

Zip Code

YOU ARE HEREBY COMMANDED TO PERSONALLY APPEAR

AND/OR

PRODUCE THE FOLLOWING:

at on the day of ,20 at A.M. P.M.

Subpoena requested by to:
Address

; and any questions should be referred
TELEPHONE:

Date Issued
Per

WORKERS' COMPENSATION COMMISSION

SHERIFF'S RETURN
­ Served and copy delivered on date indicated below ­ Unserved, by reason of Date: SHERIFF

WCC Form H-08 (09/01/05)

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