WORKERS' COMPENSATION COMMISSION
10 EAST BALTIMORE STREET BALTIMORE, MARYLAND 21202-1641
OBJECTION TO SUBPOENA OF MEDICAL RECORDS
Pursuant to Section 4-306 of Health - General Article, Annotated Code of Maryland, this OBJECTION TO SUBPOENA MEDICAL RECORDS must be filed with the Workers' Compensation Commission no later than thirty (30) days from the date the NOTICE OF INTENT TO SUBPOENA MEDICAL RECORDS (WCC Form H-08/NOI) is mailed.
I,
Claimant Name WCC Claim Number
Address
City
State
Zip Code
Hereby gives notice of objection to the disclosure of the designated medical records
Kept by: Physician Name
Address
City
State
Zip Code
and in which I received a Notice of Intent to Subpoena Medical Records, WCC Form H-08/NOI,
from which is dated .
I hereby certify that a copy of this Objection to Subpoena of Medical Records was mailed, by first class mail, postage prepaid, this day of ,2 to all parties and their attorneys.
Signature of Claimant
DATE
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WCC Form H-08/OTS (8/29/05)