Agreement On The Propriety Of Services And Selection Of Practitioner {VR06}

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: Address: WCC Number: The undersigned hereby agrees to the propriety of vocational rehabilitation services and the selection of the above-named vocational rehabilitation practitioner. Employer/Insurer Name Telephone Number Signature Date Claimant/Attorney Name Telephone Number Signature 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 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) American LegalNet, Inc. www.FormsWorkFlow.com