Fill and Sign the Wc 200b Fillable Online Request Objection for Change Form

WC -200b REQUEST / OBJECTION FOR CHANGE OF PHYSICIAN / ADDITIONAL T REAT M ENT GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST / OBJECTION FOR CHANGE OF PHYSICIAN / ADDITIONAL TREATMENT 0 REQUEST 0 OBJECTION Instructions: When you receive this complete form, you must file a response with the Board within 15 days of the date on the certificate of service (O.C.G.A. !9- 11 -6 (e)). All responses must be filed on Form WC -200b 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 Name of counsel (if represented) Address City State Zip Code INSURER / SELF- INSURER Na me Name of counsel (if represented) CLAIMS OFFICE Na me Claim Office Address E-mail Address SBW C ID# (five digit no.) City State Zip Code C. ACTION REQUESTED This action is being requested by: 0 Employee 0 Employer 0 Insurer 0 1. A request is being made for change of primary treating physician to Dr. 0 2. A request is being made for additional medical treatment to be provided by Dr. The current autho rized primary treating physician shall remain authorized. 0 3. An objection is being filed by: 0 Employee 0 Employer 0 Insurer This request / objection is based upon the following (attach supporting documentation): 0 Proximity of physician's office to employee's residence 0 Excessive/redundant pe rformance of medical procedures 0 Accessibility of physician to employee 0 Noncompliance by physician with Board Rules and procedures 0 Necessity for specialized care 0 Number of physicians who have treated th e employee 0 Language barrier 0 Prior requests for c hange of physician or treatment 0 Referral by authorized physician 0 Employee released to normal duty work by current authorized physician 0 Panel of physicians 0 Duration of treatment without apprecia ble improvement 0 Other: See Board Rule 200 (b) (2) 0 Current physician indicates nothing more to offer 0 WC/MCO internal dispute resolution process (procedure attached) D. ENTRY OF APPEARANCE 0 I hereby certify to the existence of a valid fee contract in compliance with Boa rd Rule 108 or Form W C 102B filed in compliance of Board Rule 102. (fee contract or Form W C 102B has been filed previously or is attached). E. CERTIFICATE OF SERVICE 0 I hereby certify that the parties have made a good faith effort to reach agreement on this issue, but have failed to do so to da te. I further certify that I have this day sent a copy of this form with supporting documentation to the State Board of Workers’ Compensation 270 Peachtree St, NW, Atlanta, GA 30303 -1299 and to all parties and counsel in this claim. Print Name Here Phone Number Address Signature Date City State Zip Code E-mai l GA Bar number B. PHYSICIANS / TREATMENT 1. The currently authorized treating physician is Dr.: Address Name City State Zip Code 2. Authorization is requested for: Address 0 a Change of Physician to 0 additional treatment Name City State Zip Code IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATI ON 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 VIOLATI ON (O.C.G.A. §34-9-18 AND §34 -9-19). WC -200b REVISION 07/20 14 200 b REQUEST / OBJECTION FOR CHANGE OF PHYSICIAN / ADDITIONAL TREATMENT