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Request Number is 123456
File a Claim
  • Instructions
  • Claimant Information
  • Claimant Address
  • Job Information
  • Employer Information
  • Accident Information
  • Claim Information
  • Physician Information
  • Hospital Information
  • Medical Authorization
  • Certification and Signature
Instructions
Read the below instructions to proceed with claim creation.

1. This File a Claim is only to be used by the claimant who don’t want to register to CompHub. Please note that incorrect claim may be rejected.

2. You must enter a valid email address to receive claim status information.

3. The claim must be completed in English.

4. When your claim is received and processed, you will get the Notice of Claim C-30. This will be sent via email to CompHub subscribers or via US Postal Service for non subscribers.

5. All claim applications not submitted or completed will be deleted.

6. For technical assistance, contact comphubsupport@wcc.state.md.us. For questions regarding claim process, please contact 410-368-0992

7. For other questions, please contact our Public Service office, info@wcc.state.md.us or via telephone 410-864-5100 during normal business hours.

Claimant Information
Provide the injured workers' information.
First Name
*Required
Middle Initial
Last Name
*Required
Email
Gender
Male Female
*Required
Date of Birth
*Required
Marital Status
Married Single
*Required
SSN
Phone
Claimant Address
Provide the injured workers' address.
Line 1
*Required
Line 2
City
*Required
County
State
*Required
Postal Code
*Required
Job Information
Provide the injured workers' job information.
Gross Wages Per Week
Paid full wages for day
Yes No
What is your regular work?
What was your work when injured?
Employer Information
Provide your employer name and address.

Failure to disclose information or giving false information, including information regarding any work related activity or return to work either before or after an award of benefits, may subject you to fines, imprisonment, or both, and disqualify you from receiving benefits, A CLAIMANT'S FAILURE TO COMPLETE THIS FORM IN COMPLIANCE WITH COMAR 14.09,02 MAY RESULT IN THE CLAIM BEING REJECTED. TO EXPEDITE YOUR CLAIM, YOU MAY SEND A COPY OF THE COMPLETED FORM TO YOUR EMPLOYER.

Full and correct business name of your employer
*Required
Nature of business
Phone
Line 1
*Required
Line 2
City
*Required
State
*Required
Postal Code
*Required
Accident Information
Provide accident information.
Location where accident occurred
Whom did you notify of the accident?
Occupational disease?
Yes No
*Required
Date of accident/occupational disease disablement
*Required
Describe how accidental injury/ occupational injury occurred
*Required
What body part was injured?
*Required
Claim Information
Provide accident information.
First day not worked
*Required
Amputation required?
Yes No
Employer requested to provide medical care?
Yes No
Medical care provided?
Yes No
Date returned to work
Physician Information
Provide physician information.
Physician Name
Line 1
Line 2
City
State
Postal Code
Hospital Information
Provide hospital information.
Hospital Name
Line 1
Line 2
City
State
Postal Code
If Health Insurance used, give name of Insurance Company
MARYLAND WORKERS' COMPENSATION COMMISSION
AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

Pursuant to Labor and Employment Article, §§ 9-709, 9-710, and 9-711, Annotated Code of Maryland, this authorization must be signed and filed with the Workers’ Compensation Commission of Maryland in conjunction with any claim for workers’ compensation benefits.

A. Person Covered by Authorization
This document authorizes the disclosure of protected health information regarding:
Name/Claimant
Date of Birth
Claim No:
B. Purpose of Disclosure
This document authorizes the disclosure of protected health information for the purpose of processing, adjudicating and resolving workers’ compensation claims.
C. Entities Authorized to Make Disclosure
This document authorizes any health plan, physician, healthcare professional, dentist, hospital, clinic, laboratory, pharmacy, medical facility, or other healthcare provider that has provided payment, treatment or services to me or on my behalf to disclose my protected health information consistent with this directive.
D. Entities Authorized to Receive Protected Health Information
This document authorizes the disclosure of my protected health information to the following entities and their agents: my attorney, my employer, my employer’s workers’ compensation insurer, the Subsequent Injury Fund, and the Uninsured Employers’ Fund
E. Information to be Disclosed
This document authorizes the entities listed in C to disclose protected health information that is relevant to:
1. The member of the body that was injured:  
2. The description of how the accidental injury occurred:  
3. The description of how the occupational disease occurred: 

The protected health information that may be disclosed includes, but is not limited to: history, findings, office and patient charts, files, examination and progress notes, and physical evidence.

A. I understand that I may revoke this authorization by giving written notice to all parties to my claim for workers’ compensation, except to the extent that this authorization has already been acted on prior to receipt of my revocation.

I understand that the information disclosed by this authorization may be subject to re-disclosure by the recipient to a medical manager, healthcare professional or registered rehabilitation practitioner, and others consistent with state and federal law.

By signing this form, I am authorizing the disclosure of my protected health information. This authorization is valid for one year from the date the claim amendment is filed.

Patient/Claimant Signature
Date: 02/26/2024 02:07 PM
Email:
A photocopy, facsimile or electronic transmission of this signed authorization form is valid.
Claim Filing Date: 02/26/2024
Claim No:
Certifications & Signature

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