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WC-200a CHANGE OF PHYSICIAN / ADDITIONAL TREATMENT BY CONSENT GEORGIA STATE BOARD OF WORKERS' COMPENSATION 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 OBTAININ G 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 . 07/20 11 200 a 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 medic al 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 County of Injury Address E-mail Address City State Zip Code B. PHYSICIANS / TREATMENT 1. The currently authorized treating physician is Dr.: Address Name City State Zip Code 2. The Authorization is requested for treatment by Dr.: Address 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 neces sary and reasonable medical expenses incurred as a result of treatment rendered by this physician effective / / . 2. The parties agree that additional medical treatment as no ted above may be provided to the em ployee by Dr. , and the employer is to be responsible for payment of neces sary and reasonable medical expenses incurred as a result of treatm ent, 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 Address Address City State Zip Code City State Zip Code E-mail Address GA Bar Number E-mail Address GA Bar Number D. CERTIFICATION I hereby certify that I have today sent a copy of th is form to all parties, counsel and the above-named med ical providers, and to the State Board of Workers’ Compensation, 270 Peachtree Street, N.W., At lanta, Georgia 30303-1299 Signature E-mail Date Phone Number