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Fill a Valid Wc 200A Georgia Template

The WC-200A form is a crucial document used in Georgia's workers' compensation system, specifically for requesting a change of physician or additional treatment by consent. This form must be completed and filed with the Georgia State Board of Workers' Compensation after submitting either a Form WC-1 or WC-14. Proper execution of the WC-200A ensures that the necessary medical treatment is authorized and that the employer agrees to cover the associated costs.

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Contents

The WC-200A form is an essential document for employees navigating the workers' compensation system in Georgia. This form facilitates a change of physician or requests additional treatment by consent, ensuring that employees receive the necessary medical care for their injuries. Before submitting the WC-200A, it is crucial to have previously filed either a Form WC-1 or WC-14 with the Georgia State Board of Workers' Compensation. The form requires detailed information, including the employee's claim number, personal details, and specifics about the current and proposed treating physicians. It also outlines the agreement between the employee and employer regarding the change or addition of medical treatment. Signatures from both parties confirm their consent, making the changes official. Furthermore, the form includes a certificate of service, ensuring that all relevant parties are notified of the changes. Understanding the purpose and requirements of the WC-200A can significantly impact the quality of care an injured worker receives, ultimately supporting their recovery and return to work.

Wc 200A Georgia Example

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.

Date of Injury

A. IDENTIFYING INFORMATION

EMPLOYEE

County of Injury

Mailing Address

E-mail Address

City

State

Zip Code

B. PHYSICIANS / TREATMENT

1.The currently authorized treating physician is Dr.: Name

2.The Authorization is requested for treatment by Dr.:

Mailing Address

City

Mailing Address

State

Zip Code

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)

Employee / Attorney Name – Print

Employer / Attorney Name – Print

Mailing Address

City

State

Zip Code

City

State

Zip Code

E-mail Address

GA Bar Number

E-mail Address

GA Bar Number

D. CERTIFICATE OF SERVICE

 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).

WC-200a	REVISION 12/2018	200a	CHANGE OF PHYSICIAN / ADDITIONAL
			TREATMENT BY CONSENT

Download Wc 200A Georgia

Document Breakdown

Fact Name	Fact Description
Purpose of the Form	The WC-200A form is used to request a change of physician or additional treatment for an employee under Georgia's workers' compensation system.
Filing Requirement	Before submitting the WC-200A form, a Form WC-1 or WC-14 must have been previously filed with the Georgia State Board of Workers' Compensation.
Governing Law	This form operates under the authority of O.C.G.A. §34-9-200 (b), which outlines the procedures for changes in medical treatment within the workers' compensation framework.
Certification of Service	The individual submitting the form must certify that copies have been sent to all relevant parties, including the State Board of Workers' Compensation, ensuring proper notification.

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