Change Of Physician-Additional Treatment By Consent {WC-200a}

WC-200a GEORGIA STATE BOARD OF WORKERS' COMPENSATION CHANGE OF PHYSICIAN / ADDITIONAL TREATMENT BY CONSENT 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. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION EMPLOYEE E-mail Address County of Injury 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.: Name 3. The additional treatment authorized is: Address City Address State Zip Code City State Zip Code 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 / This agreement is made by: / . The primary treating physician will remain Dr. Signature (Employee or Representative) Signature (Employer or Representative) Employee / Attorney Name Address Print Employer / Attorney Name Address Print City E-mail Address State Zip Code GA Bar Number City E-mail Address State Zip Code GA Bar Number D. CERTIFICATION 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 -1299 Signature E-mail Date Phone Number -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 . 07/2011 200a CHANGE OF PHYSICIAN / ADDITIONAL TREATMENT BY CONSENT American LegalNet, Inc. www.FormsWorkFlow.com