Revised Form – Request for Action on Filed Issues (H-25R 08/2017) - This form is revised and available as a fillable PDF form on our Forms and Instructions page.  It is revised to clarify required actions and items for "Set-Withs" and includes the option for “Healthcare Provider” as a filing Party.

ALL claims to be included in the “Set-With” must be listed in the space provided on the form, EACH of those claims MUST have Pending Issues AND a SEPARATE  “Set-With” form (H25R) filed in EACH claim.  If the “Set-With” does not meet these requirements, a notice will be sent  advising that the request is not granted because it is incomplete and not in compliance with COMAR §14.09.03.15(A)(3).  No action will be taken on the request.

We do not accept form filing via email/attachment or FAX.  Please begin using the new form immediately.