WCC Form VR06 "Agreement on the Propriety of Services and Selection of Practitioner" - Maryland

What Is WCC Form VR06?

This is a legal form that was released by the Maryland Workers' Compensation Commission - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2014;
  • The latest edition provided by the Maryland Workers' Compensation Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of WCC Form VR06 by clicking the link below or browse more documents and templates provided by the Maryland Workers' Compensation Commission.

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Download WCC Form VR06 "Agreement on the Propriety of Services and Selection of Practitioner" - Maryland

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WORKERS’ COMPENSATION COMMISSION
AGREEMENT ON THE PROPRIETY OF SERVICES AND SELECTION OF PRACTITIONER
INSTRUCTIONS: This form must be submitted to the Workers’ Compensation Commission and
a copy sent to the selected vocational rehabilitation practitioner.
WCC CLAIM NUMBER:
CLAIMANT:
EMPLOYER:
INSURER:
Agreed Upon Vocational Rehabilitation Practitioner:
Practitioner Name:
WCC Number:
Address:
The undersigned hereby agrees to the propriety of vocational rehabilitation services and the selection
of the above-named vocational rehabilitation practitioner.
Employer/Insurer Name
Signature
Telephone Number
Date
Claimant/Attorney Name
Signature
Telephone Number
Date
NOTICE
The practitioner may not contact the above claimant or initiate vocational rehabilitation
services until the practitioner has received a copy of this notice.
CERTIFICATION OF SERVICE
I hereby certify that on this
day of
, 20
, I mailed, postage prepaid, a copy of
this AGREEMENT and any attached documentation to all parties and their attorneys.
Signature
Telephone
CLICK HERE TO CLEAR THE FORM
10 East Baltimore Street Baltimore, Maryland 21202-1641
410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us
WCC Form VR06 (04/14)
WORKERS’ COMPENSATION COMMISSION
AGREEMENT ON THE PROPRIETY OF SERVICES AND SELECTION OF PRACTITIONER
INSTRUCTIONS: This form must be submitted to the Workers’ Compensation Commission and
a copy sent to the selected vocational rehabilitation practitioner.
WCC CLAIM NUMBER:
CLAIMANT:
EMPLOYER:
INSURER:
Agreed Upon Vocational Rehabilitation Practitioner:
Practitioner Name:
WCC Number:
Address:
The undersigned hereby agrees to the propriety of vocational rehabilitation services and the selection
of the above-named vocational rehabilitation practitioner.
Employer/Insurer Name
Signature
Telephone Number
Date
Claimant/Attorney Name
Signature
Telephone Number
Date
NOTICE
The practitioner may not contact the above claimant or initiate vocational rehabilitation
services until the practitioner has received a copy of this notice.
CERTIFICATION OF SERVICE
I hereby certify that on this
day of
, 20
, I mailed, postage prepaid, a copy of
this AGREEMENT and any attached documentation to all parties and their attorneys.
Signature
Telephone
CLICK HERE TO CLEAR THE FORM
10 East Baltimore Street Baltimore, Maryland 21202-1641
410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us
WCC Form VR06 (04/14)