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

Form WC 200A Georgia is a vital form within the paper work procession utilized by many companies as part of their Human Resources process. This particular form is covered under workers' compensation insurance and confirmed through certification for compliant filing. The example Georgia form is ideal for workplace injuries occurring across many types of industries, such as construction companies, healthcare organizations, schools, and any location subject to certain local laws. It can help provide employers with an easy template to organize information related to the taken employee's remedy benefits that contribute to rapid assessment results. Valuable insights can be drawn by HR offices into managed care costs and influencing cases regarding necessary activities taken after an injury or illness has been declared onsite. Form WC 200AGeorgia empowers human resource teams faster processing combined with lower overall expenses, leading firms to reap powerful benefits throughout the course of operations.

Form Wc 200A Georgia PDF Details

Form WC 200A is a document that is used to report workers' compensation information in the state of Georgia. This form must be completed and filed by all employers who have at least one employee working in the state of Georgia. The information on this form will help the Georgia Workers' Compensation Division to ensure that employers are meeting their obligations under the law with respect to workers' compensation insurance. Employers who do not comply with the workers' compensation laws can face significant penalties. Completing and filing Form WC 200A is therefore very important for anyone doing business in Georgia.

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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