Free Notice of Intent to Subpoena Medical Records & Certificate of Service (WCC H-08/NOI 08/2005) - Maryland


File Size: 78.8 kB
Pages: 1
Date: August 30, 2005
File Format: PDF
State: Maryland
Category: Workers Compensation
Author: MD WCC Webmaster
Word Count: 346 Words, 2,166 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.wcc.state.md.us/PDF/PDF_Forms/NOI_COS.pdf

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Preview Notice of Intent to Subpoena Medical Records & Certificate of Service (WCC H-08/NOI 08/2005)
WORKERS' COMPENSATION COMMISSION
10 EAST BALTIMORE STREET BALTIMORE, MARYLAND 21202-1641

NOTICE OF INTENT TO SUBPOENA MEDICAL RECORDS & CERTIFICATE OF SERVICE
Pursuant to 4-306 of the Health - General Article, Annotated Code of Maryland: Take notice that the medical records regarding the Patient named below, will be subpoenaed pursuant to the attached subpoena from the healthcare provider (Physician) below. Please examine these papers carefully. If you have any objection to the production of these documents, you must file an OBJECTION TO SUBPOENA MEDICAL RECORDS (WCC Form H-08/OTS) no later than thirty (30) days from the date this NOTICE OF INTENT TO SUBPOENA MEDICAL RECORDS is mailed. For example, an Objection may be granted if the records are not relevant to the Issues in this case, the request unduly invades your privacy, or causes you specific harm. If you believe you need further legal advice about this matter, you should consult your attorney. THIS SUBPOENA DOES DOES NOT (MARK ONE) SEEK PRODUCTION OF MENTAL HEALTH RECORDS.

This form gives notice of the undersigned's intent to subpoena the medical records of:
Patient WCC Claim Number

Address Kept by: Physician Name

City

State

Zip Code

Address

City

State

Zip Code

The Subpoena Duces Tecum for Medical Records is requested to be available by/on: MM/DD/YYYY

CERTIFICATION OF SERVICE
Pursuant to Health General 4-306, I hereby certify that a copy of this NOTICE OF INTENT TO SUBPOENA MEDICAL RECORDS and the subpoena duces tecum were mailed, by certified mail, postage prepaid, this day of ,2 to the person of interest and counsel.

Requesting Party Name

Requesting Party Signature

Address

City

State

Zip Code

Telephone Number

30-Day Certification
Do not complete the following certification until 30 days have elapsed since this Notice was mailed. I further certify that the person in interest has not objected to the disclosure of the designated medical records or that said objection has been resolved and that 30 (thirty) days have elapsed since Notice was sent.

Requesting Party Name

Requesting Party Signature DATE:

WCC Form H-08/NOI (8/29/05)

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