Georgia Form Wc 104 PDF Details

In the landscape of Georgia's workers' compensation system, the WC-104 form plays a pivotal role in bridging the gap between recovery and returning to work for employees who have sustained injuries on the job. This essential document, formally titled "Notice to Employee of Medical Release to Return to Work with Restrictions or Limitations," acts as a communication tool mandated by the Georgia State Board of Workers' Compensation. It is employed by employers to formally notify an injured worker when their authorized treating physician deems them fit to resume work, albeit with certain restrictions or limitations. Grounded in the regulations set forth by O.C.G.A. §34-9-104(a) and Board Rule 104, the form requires meticulous adherence to protocol, including the necessity to attach the medical report detailing the worker's specific limitations. This notification not only serves to update the employee on their potential shift from Total Temporary Disability (TTD) to Temporary Partial Disability (TPD) benefits but also underpins the legal framework ensuring that the transition back to work is handled with the requisite care and attention to the employee's medical condition. Moreover, the inclusion of a warning about the legal repercussions of making false statements underscores the seriousness with which this process is taken, safeguarding the integrity of the workers' compensation system. The WC-104 form, thus, encapsulates a crucial step in the journey of recovery to reintegration into the workforce for many Georgians, balancing the need for employee welfare with the operational needs of employers.

QuestionAnswer
Form NameGeorgia Form Wc 104
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswc104 wc 104 ga form

Form Preview Example

WC-104 NOTICE TO EMPLOYEE OF MEDICAL RELEASE TO RETURN TO WORK WITH RESTRICTIONS OR LIMITATIONS

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

NOTICE TO EMPLOYEE OF MEDICAL RELEASE TO RETURN TO WORK

WITH RESTRICTIONS OR LIMITATIONS

Instructions: The employer shall use this form to notify an employee that the authorized treating physician has released the employee to return to work with restrictions or limitations, as required by O.C.G.A. §34-9-104(a) and Board Rule 104. This form, with attached medical report, must be sent to the employee and counsel for the employee, within 60 days of the release to return to work. This form, along with attached medical report, should only be filed with the Board as an attachment to a Form WC-2 when converting benefits from TTD to TPD.

Board Claim No.

Employee Last Name

Employee First Name

M.I.

SSN or Board Tracking #

Date of Injury

 

 

 

A. IDENTIFYING INFORMATION

 

 

 

County of Injury

 

 

INSURER/

Name

 

 

EMPLOYEE

 

 

 

 

 

 

 

 

 

SELF-INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

Name

 

 

 

 

 

 

CLAIMS OFFICE

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

Address

 

 

 

 

 

 

 

 

 

 

E-mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

 

Name

 

 

 

 

 

 

EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

SBWC ID# (five digit no.)

 

Insurer/Self-Insurer File #

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

Phone Number

 

 

 

 

 

 

 

 

 

 

E-mail

 

 

E-mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. NOTICE TO EMPLOYEE

1.Your injury, which occurred on or after July 1, 1992, is not catastrophic, as defined in O.C.G.A. 34-9-200.1(g).

2.You are receiving income benefits, and are not working.

3.Your authorized treating physician, who is

has released you to work with restrictions or limitations on

4.The limitations from the physician are as follows:

A copy of the physician's report, which authorizes your release and describes your limitations, is attached.

5.Because you have been released to return to work with restrictions, your income benefits will be reduced from $

 

per week to $

 

per week on

 

, unless you return to work at an earlier date.

 

I certify that I have today sent a copy of this form with the attached medical report to the employee and counsel for the employee, if represented.

Print Name

Date

Signature

Phone Number and Ext

Employer / Insurer

E-mail

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-104

REVISION . 07/2011

104

NOTICE TO EMPLOYEE OF MEDICAL RELEASE TO

RETURN TO WORK WITH RESTRICTIONS OR LIMITATIONS

Georgia Form Wc 104 isn’t the one you’re looking for?

Related Documents