Form Wc 200A Georgia – Fill Out and Use This PDF

The WC-200A Georgia form, officially known as the "Change of Physician/Additional Treatment by Consent," is a vital document that comes into play when an individual receiving worker's compensation benefits in Georgia needs to change their authorized treating physician or requires additional medical treatment. This form is utilized under the specifications laid out by the Georgia State Board of Workers' Compensation, ensuring that workers have the necessary consent for changes in their medical care to be officially recognized and approved. For a smooth processing experience, it is essential that the WC-200A form is correctly filled out and submitted following a prior WC-1 or WC-14 form submission.

To ensure your rights to suitable medical treatment and care are upheld, making sure the WC-200A form is accurately filled out and filed is paramount. Click the button below to start the process of filling out your form.

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Form Wc 200A Georgia PDF Details

Navigating the intricacies of workers' compensation in Georgia can be a daunting task for both employees and employers. Key among the forms utilized in this process is the WC-200a, a vital document designed to facilitate the change of physician or addition of treatment by consent under the Georgia State Board of Workers’ Compensation rules. This form, necessary once a Form WC-1 or WC-14 has been filed, helps streamline the process of modifying medical care providers or treatments related to a workplace injury. It necessitates detailed information about the employee, the currently authorized treating physician, and the proposed changes to treatment or care providers. The form also encapsulates an agreement section where the consented changes and the responsible party for the medical expenses are clearly defined. Once properly executed and submitted, along with notifying all relevant parties, the document serves as an officially approved modification to the employee’s medical treatment under the workers' compensation claim. Moreover, it underscores the importance of adherence to the legal obligations laid down by the Georgia State Board of Workers' Compensation, including penalties for falsifying information to obtain benefits unlawfully. The WC-200a thus plays a crucial role in ensuring that changes in an injured worker's medical treatment are transparent, consensual, and in compliance with state regulations.

Question	Answer
Form Name	Form Wc 200A Georgia
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	workers compensation froms georgia, georgia 200a, wc change form, ga change workers compensation

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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.

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

Form Wc 200A Georgia – Fill Out and Use This PDF

Form Wc 200A Georgia PDF Details

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