Free Request for Document Correction - (WCC C90R, 2/2008 - Maryland

WORKERS' COMPENSATION COMMISSION

REQUEST FOR DOCUMENT CORRECTION
INSTRUCTIONS: This form is to be used by a party ONLY to notify the Commission that an undisputed factual error exists in a document that
has been filed in a specific workers' compensation claim. The mistake may be an error in the document as originally submitted, or may be due to human or technological error. Any party identifying an error on a document in the Commission's files (paper or electronic) should complete this form and submit it to the Commission for consideration. The form should be submitted without a cover letter. For example, if all parties agree that the Date of Accident as originally submitted on a claim form is incorrect this form may be used to obtain a correction in the Commission's records. If, however, a factual dispute exists with respect to the Date of Accident and the party originally submitting the information believes it is factually accurate, the matter should not be categorized as a document correction. The dispute should be resolved at a hearing together with other matters upon which the parties do not agree.

THIS FORM MAY NOT BE USED TO AMEND AN EMPLOYEE CLAIM FORM. The form Claim Amendment (C-3) must be used and include the fully completed and executed Authorization for Disclosure of Health Information (page 2).

An error has been identified in a claim document on file with the Workers' Compensation Commission as described below. This submission requests that corrective action be taken as soon as possible.

CLAIM NUMBER: DOCUMENT TYPE:

CLAIMANT NAME: DOCUMENT DATE:

ERROR DESCRIPTION:

CORRECTION REQUESTED:

REQUESTED BY:

CLAIMANT

CLAIMANT'S ATTY

EMPLOYER/INSURER

EMP/INS ATTY

OTHER:

FULL NAME (PRINTED)

SIGNATURE

DATE OF REQUEST

Street Address

City

State

ZIP Code

Telephone

Email Address

CLICK HERE TO CLEAR THE FORM
10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: [email protected] Web: http://www.wcc.state.md.us
WCC C90R (02/12/2008)