Fill and Sign the Wc 20a Form

WC-20a MEDICAL REPORT 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 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 -20a REVISION 07/2017 20 a MEDICAL REPORT MEDICAL REPORT  Initial  Interim  Final FAILURE TO SUBMIT THIS REPORT TO THE INSURER WILL JEOPARDI ZE PAYMENT OF FEES Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury EMPLOYEE Address City State Zip Code Phone Number EMPLOYER Name Address Phone Number City State Zip Code INSURER / SELF-INSURER Name Address CLAIMS OFFICE Name Phone Number City State Zip Code 1. Date disability began 2. Date of first treatment 3. Services authorized by  Employer 4. Patient History  Dr. (name):  Other (specify): 5. Findings from Examination 6. Describe Diagnosis ICD- 10 code 7. Describe Treatment 8. Prognosis 9. Date of maximum recovery 10. Doctors estimate of length of disability 11. Catastrophic Case Management Recommended 12. Date discharged as cured 13. Date patient stopped treatment without an order 14. Date patient refused treatment 15. a. Date patient able to return to work without restrictions 16. Hospital name and address if hospitalized 17. Does employee have any permanent disability?  Yes If yes, specify part of body  No b. Date patient able to return to work with restrictions c. List any restrictions Percentage based upon AMA guides % Date of Service CPT/CDT Code Medical, Surgical, and Dental Services / Drugs (itemize) Units Amount Doctor’s Name FEIN / SSN Address Doctor’s Signature Date City State Zip Code FILE THREE (3) COPIES WITH INSURER OR SELF-INSURER (PLEASE TYPE)