WCC Form H44 "Claimant's Consent to Pay Fees and Costs" - Maryland

What Is WCC Form H44?

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 March 1, 2018;
  • 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 H44 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 H44 "Claimant's Consent to Pay Fees and Costs" - Maryland

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WORKERS' COMPENSATION COMMISSION
CLAIMANT’S CONSENT TO PAY FEES AND COSTS
This form must be submitted to the Workers' Compensation Commission in accordance with COMAR
14.09.04.02 and, regardless of whether the matter is resolved by award, settlement or stipulation, all fees
and costs must be itemized on the form below.
If you do not calculate the counsel fee in accordance with COMAR 14.09.04.03, you consent to the
Commission determining the fee on your behalf.
WCC Claim Number:
Claimant:
Employer:
Insurer:
I, the undersigned, hereby certify that my attorney has explained to me the amounts allowable by the
Commission as counsel fee under the Maryland Workers' Compensation Commission Schedule of
Attorney's Fees, COMAR 14.09.04.03 and, I consent to the award of a fee to my attorney in
accordance with the schedule.
I further consent to the allowance of a fee in accordance with the Maryland Workers' Compensation
Commission Guide of Medical and Surgical Fees, COMAR 14.09.08 to my physician(s) for services
performed at my or my counsel's request.
Attorney Fees: Copies of receipts for advanced expenses MUST be attached. DO NOT attach
ledger sheets. Medical Fees: Copies of medical bills with CPT Codes MUST be attached for
consideration. DO NOT attach medical reports.
*Please attach additional pages as necessary
I agree that the fees allowed may be deducted from the compensation benefits awarded to me, in the
manner prescribed by the Workers' Compensation Commission or as directed by law.
Claimant Signature
Date
I hereby certify that (1) I have earned the amounts allowable by the Commission as counsel fee
under COMAR 14.09.04.03 and, (2) any costs for which the undersigned is seeking repayment
actually were advanced by the undersigned attorney.
Attorney Signature
Attorney Name
Attorney Telephone Number
CLEAR THIS FORM
PRINT THIS FORM
WCC Form H44 03/2018
10 East Baltimore Street · Baltimore, Maryland 21202-1641
Page 1 of 1
WORKERS' COMPENSATION COMMISSION
CLAIMANT’S CONSENT TO PAY FEES AND COSTS
This form must be submitted to the Workers' Compensation Commission in accordance with COMAR
14.09.04.02 and, regardless of whether the matter is resolved by award, settlement or stipulation, all fees
and costs must be itemized on the form below.
If you do not calculate the counsel fee in accordance with COMAR 14.09.04.03, you consent to the
Commission determining the fee on your behalf.
WCC Claim Number:
Claimant:
Employer:
Insurer:
I, the undersigned, hereby certify that my attorney has explained to me the amounts allowable by the
Commission as counsel fee under the Maryland Workers' Compensation Commission Schedule of
Attorney's Fees, COMAR 14.09.04.03 and, I consent to the award of a fee to my attorney in
accordance with the schedule.
I further consent to the allowance of a fee in accordance with the Maryland Workers' Compensation
Commission Guide of Medical and Surgical Fees, COMAR 14.09.08 to my physician(s) for services
performed at my or my counsel's request.
Attorney Fees: Copies of receipts for advanced expenses MUST be attached. DO NOT attach
ledger sheets. Medical Fees: Copies of medical bills with CPT Codes MUST be attached for
consideration. DO NOT attach medical reports.
*Please attach additional pages as necessary
I agree that the fees allowed may be deducted from the compensation benefits awarded to me, in the
manner prescribed by the Workers' Compensation Commission or as directed by law.
Claimant Signature
Date
I hereby certify that (1) I have earned the amounts allowable by the Commission as counsel fee
under COMAR 14.09.04.03 and, (2) any costs for which the undersigned is seeking repayment
actually were advanced by the undersigned attorney.
Attorney Signature
Attorney Name
Attorney Telephone Number
CLEAR THIS FORM
PRINT THIS FORM
WCC Form H44 03/2018
10 East Baltimore Street · Baltimore, Maryland 21202-1641
Page 1 of 1