Panel Of Physicians {WC-P1} | Pdf Fpdf Doc Docx | Georgia

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Panel Of Physicians {WC-P1} | Pdf Fpdf Doc Docx | Georgia

Panel Of Physicians {WC-P1}

This is a Georgia form that can be used for Workers Comp.

Alternate TextLast updated: 8/16/2006

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<document>(This notice must be posted in a conspicuous place readily accessible to the employee at all times.)OFFICIAL NOTICE This business operates under the Georgia Workers' Compensation Law. WORKERS MUST REPORT ALL ACCIDENTS IMMEDIATELY TO THE EMPLOYER BY ADVISING THE EMPLOYER PERSONALLY, AN AGENT, REPRESENTATIVE, BOSS, SUPERVISOR, OR FOREMAN.If a worker is injured at work, the employer shall pay medical and rehabilitation expenses within the limits of the law. In some cases the employer will also pay a part of the worker's lost wages. Work injuries and occupational diseases should be reported in writing whenever possible. The worker may lose the right to receive compensation if an accident is not reported within 30 days. The employer will supply free of charge, upon request, a form for reporting accidents and will also furnish, free of charge, information about workers' compensation. The employer will also furnish to the employee, upon request, copies of board forms on file with the employer pertaining to an employee's claim. A worker injured on the job must select a doctor from the list below. The minimum panel shall consist of at least six physicians, including an orthopedic surgeon with no more than two physicians from industrial clinics. Further, this panel shall include one minority physician, whenever feasible (see Rule 201 for definition of minority physician). The Board may grant exceptions to the required size of the panel where it is demonstrated that more than four physicians are not reasonably accessible. One change of doctor, from the list, may be made without permission. Further changes require the permission of the employer or the State Board of Workers' Compensation.COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .State Board of Workers' Compensation 270 Peachtree Street, N.W. Atlanta, Georgia 30303-1299 404-656-3818 or 1-800-533-0682 http://www.ganet.org/sbwc/THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomname/address/phonename/address/phonename/address/phoneYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.name/address/phonename/address/phonename/address/phone, one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Additional doctors may be added on a separate sheet) The insurance company providing coverage for this business under the Workers' Compensation Law is:(Attorney must sign above and type name below)NameAttorney(s) foraddressphoneWillfully 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).Office and P.O. AddressWC-P1 (7/2002)Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com</document>

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