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    Georgia State Board of Workers' Compensation: Change of Physician / Additional Treatment by Consent

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    jeffdandel
    This document is a form for changing or adding physicians for a workers' compensation claim in Georgia. It requires identifying information about the employee and claim. Section B allows selecting a new authorized treating physician or requesting authorization for additional treatment from another doctor. Section C is where the employee and employer agree to the changes by signature. Section D requires certification that all parties were notified of the changes.

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    Georgia State Board of Workers' Compensation: Change of Physician / Additional Treatment by Consent

    Uploaded by

    jeffdandel
    33 views1 page
    This document is a form for changing or adding physicians for a workers' compensation claim in Georgia. It requires identifying information about the employee and claim. Section B allows selecting a new authorized treating physician or requesting authorization for additional treatment from another doctor. Section C is where the employee and employer agree to the changes by signature. Section D requires certification that all parties were notified of the changes.

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    WC-200a

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    This document is a form for changing or adding physicians for a workers' compensation claim in Georgia. It requires identifying information about the employee and claim. Section B allows selecting a new authorized treating physician or requesting authorization for additional treatment from another doctor. Section C is where the employee and employer agree to the changes by signature. Section D requires certification that all parties were notified of the changes.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    33 views1 page

    Georgia State Board of Workers' Compensation: Change of Physician / Additional Treatment by Consent

    Uploaded by

    jeffdandel
    This document is a form for changing or adding physicians for a workers' compensation claim in Georgia. It requires identifying information about the employee and claim. Section B allows selecting a new authorized treating physician or requesting authorization for additional treatment from another doctor. Section C is where the employee and employer agree to the changes by signature. Section D requires certification that all parties were notified of the changes.

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    WC-200a CHANGE OF PHYSICIAN / ADDITIONAL TREATMENT BY CONSENT

    GEORGIA STATE BOARD OF WORKERS' COMPENSATION


    CHANGE OF PHYSICIAN / ADDITIONAL TREATMENT BY CONSENT
    Instructions: Prior to filing this form with the Board, a Form WC-1 or WC-14 must have been previously filed with the Board. When properly executed and
    filed with the Board, with copies provided to the named medical provider(s), this form will be deemed approved, and made the order of the Board pursuant
    to O.C.G.A. § 34-9-200 (b).
    Board Claim No. Employee Last Name Employee First Name M.I. Social Security Number Date of Injury

                                     

    A. IDENTIFYING INFORMATION
    County of Injury Address
    EMPLOYEE            
    E-mail Address City State Zip Code

                           

    B. PHYSICIANS / TREATMENT
    Address
    1. The currently authorized treating physician is Dr.:
         
    Name       City State Zip Code
                     
    Address
    2. The Authorization is requested for treatment by Dr.:
         
    Name       City State Zip Code
                     
    3. The additional treatment authorized is:

         

    C. AGREEMENT
    1. The parties agree that a change in treating physician to Dr.       is authorized,
    and the employer is to be responsible for payment of necessary and reasonable medical expenses incurred as a result of treatment rendered
    by this physician effective       /       /       .
    2. The parties agree that additional medical treatment as noted above may be provided to the employee by
    Dr.       ,
    and the employer is to be responsible for payment of necessary and reasonable medical expenses incurred as a result of treatment, effective
          /       /       . The primary treating physician will remain Dr.       .
    This agreement is made by:
               
    Signature (Employee or Representative) Signature (Employer or Representative)

    Address Address

               
    City State Zip Code City State Zip Code
                                       
    E-mail Address GA Bar Number E-mail Address GA Bar Number

                           

    D. CERTIFICATION
    I hereby certify that I have today sent a copy of this form to all parties, counsel and the above-named medical providers, and to the State Board of
    Workers’ Compensation, 270 Peachtree Street, N.W., Atlanta, Georgia 30303-1299
    Signature E-mail Date Phone Number

                           

    IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov

    WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19).

    CHANGE OF PHYSICIAN / ADDITIONAL


    WC-200a REVISION . 07/2007 200a TREATMENT BY CONSENT

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