Free MD WCC Objection to Subpoena for Medical Records - Maryland


File Size: 67.7 kB
Pages: 1
Date: September 13, 2005
File Format: PDF
State: Maryland
Category: Workers Compensation
Author: MD WCC Webmaster
Word Count: 169 Words, 1,031 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.wcc.state.md.us/PDF/PDF_Forms/OTS_H08.pdf

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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)