Request To Become A Party At Interest {WC-206}

WC-206 REQUEST TO BECOME A PARTY AT INTEREST GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST TO BECOME A PARTY AT INTEREST PURSUANT to O.C.G.A !34-9-206 Instructions: Pursuant to O.C.G.A !34-9-206, any group insurance company or other health care provider who has made payments on the employee's behalf or provided medical services and who wishes to be named a party at interest to obtain reimbursement for those expenses which have been paid, shall file this form, including supporting documentation, with the State Board of Workers' Compensation, 270 Peachtree Street, N.W., Atlanta, Georgia 30303-1299. Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION County of Injury Address EMPLOYEE Employee E-mail City State Zip Code Name EMPLOYER Address INSURER/ SELF-INSURER CLAIMS OFFICE Address Name Name City State Zip Code City State Zip Code Employer E-mail Claims E-mail B. NOTICE Notice is hereby given that: (Print Name Group Insurance Company or Healthcare Provider) Address Phone City State Zip Code E-mail has made payments or provided medical services in the amount of $ on the employee's behalf for medical treatment, and desires to be made a party at interest in this claim in order to demonstrate that the employer/workers' compensation carrier are responsible for reimbursement for funds so expended, should liability be established under Title 34-9. C. CERTIFICATION 2 I hereby certify that I have sent a copy of this form to all parties and counsel in this claim, and to the State Board of Workers' Compensation, 270 Peachtree Street, N.W., Atlanta, Georgia 30303-1299 Signature Date Print Name Here Phone E-mail GA Bar number 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-206 REVISION 07/2014 206 REQUEST TO BECOME A PARTY AT INTEREST American LegalNet, Inc. www.FormsWorkFlow.com