Last updated: 5/17/2016
Medical Report {WC-20(a)}
Start Your Free Trial $ 13.99What you get:
- Instant access to fillable Microsoft Word or PDF forms.
- Minimize the risk of using outdated forms and eliminate rejected fillings.
- Largest forms database in the USA with more than 80,000 federal, state and agency forms.
- Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
- Trusted by 1,000s of Attorneys and Legal Professionals
Description
WC-20a MEDICAL REPORT GEORGIA STATE BOARD OF WORKERS' COMPENSATION MEDICAL REPORT 2 Board Claim No. Employee Last Name Initial 2 Interim 2 Final M.I. SSN or Board Tracking # FAILURE TO SUBMIT THIS REPORT TO THE INSURER WILL JEOPARDIZE PAYMENT OF FEES Employee First Name Date of Injury Address City State Zip Code Phone Number EMPLOYEE Name Address EMPLOYER Phone Number City State Zip Code INSURER / SELF-INSURER CLAIMS OFFICE 1. Date disability began Name Address Name Phone Number City State Zip Code 2. Date of first treatment 3. Services authorized by 2 4. Patient History Employer Dr. (name): Other (specify): 2 2 5. Findings from Examination 6. Describe Diagnosis ICD-10 code 7. Describe Treatment 8. Prognosis 9. Date of maximum recovery 12. Date discharged as cured 15. 10. Doctors estimate of length of disability 13. Date patient stopped treatment without an order 16. Hospital name and address if hospitalized 11. Catastrophic Case Management Recommended 14. Date patient refused treatment 17. Does employee have any permanent disability? a. Date patient able to return to work without restrictions b. Date patient able to return to work with restrictions 2 2 Yes No If yes, specify part of body c. List any restrictions Percentage based upon AMA guides Date of Service CPT Code Medical and Surgical Services / Drugs (itemize) Units Amount % Doctor's Name Doctor's Signature FEIN / SSN Address Date City State Zip Code FILE THREE (3) COPIES WITH INSURER OR SELF-INSURER (PLEASE TYPE) 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 02/2016 20a MEDICAL REPORT American LegalNet, Inc. www.FormsWorkFlow.com
Related forms
-
Request For Settlement Mediation
Georgia/Workers Comp/ -
Wage Statement
Georgia/Workers Comp/ -
Request-Objection For Change Of Physician-Additional Treatment
Georgia/Workers Comp/ -
Standard Coverage Form - Group Self Insurance Fund Members
Georgia/Workers Comp/ -
Attorney Fee Approval
Georgia/Workers Comp/ -
Attorney Leave Of Absence
Georgia/Workers Comp/ -
Change Of Physician-Additional Treatment By Consent
Georgia/Workers Comp/ -
Credit-Reduction In Benefits
Georgia/Workers Comp/ -
Job Analysis
Georgia/Workers Comp/ -
Medical Report
Georgia/Workers Comp/ -
Notice Of Claim-Request For Hearing-Request For Mediation
Georgia/Workers Comp/ -
Attorney Certification For No Liability Stipulations
Georgia/Workers Comp/ -
Rehab Objection
Georgia/Workers Comp/ -
Notice To Employee Of Medical Release To Return To Work
Georgia/Workers Comp/ -
Credit
Georgia/Workers Comp/ -
Employers First Report Of Injury Or Occupational Disease
Georgia/Workers Comp/ -
Notice To Controvert
Georgia/Workers Comp/ -
Case Progress Report
Georgia/Workers Comp/ -
Standard Coverage Form
Georgia/6 Workers Comp/ -
Request For Documents To Parties
Georgia/Workers Comp/ -
Motion-Objection To Motion
Georgia/Workers Comp/ -
Attorney Withdrawal Lien
Georgia/Workers Comp/ -
Change Of Physician Additional Treatment By Consent
Georgia/Workers Comp/ -
Request Objection For Change Of Physician Additional Treatment
Georgia/Workers Comp/ -
Request For Authorization Of Treatment Or Testing By Authorized Medical Provider
Georgia/Workers Comp/ -
Request To Become A Party At Interest
Georgia/Workers Comp/ -
Notice To Employee Of Offer Of Suitable Employment
Georgia/Workers Comp/ -
Request To Become A Party Of Interest
Georgia/Workers Comp/ -
Wage Documentation
Georgia/Workers Comp/ -
Request For Rehab Conference
Georgia/Workers Comp/ -
Catastrophic Rehabilitation Release
Georgia/Workers Comp/ -
Request For Change Of Address
Georgia/Workers Comp/ -
Subpoena
Georgia/Workers Comp/ -
WC-MCO Panel
Georgia/Workers Comp/ -
Request For Copy Of Board Records
Georgia/Workers Comp/ -
Notice Of Claim
Georgia/6 Workers Comp/ -
Request To Amend Information On A Form WC-14
Georgia/Workers Comp/ -
Application For Lump Sum Advance Payment
Georgia/Workers Comp/ -
Request For Rehabilitation
Georgia/Workers Comp/ -
Employees Request For Catastrophic Designation
Georgia/Workers Comp/ -
Rehabilitation Transmittal Form
Georgia/Workers Comp/ -
Individualized Rehabilitation Plan
Georgia/Workers Comp/ -
Request For Rehabilitation Closure
Georgia/Workers Comp/ -
Request To Change Information
Georgia/Workers Comp/ -
Panel Of Physicians
Georgia/Workers Comp/ -
Notice Of Payment Or Suspension Of Benefits
Georgia/Workers Comp/ -
Notice Of Payment Or Suspension Of Death Benefits
Georgia/Workers Comp/ -
Notice Of Election Or Rejection Of Workers Compensation Coverage
Georgia/Workers Comp/ -
Consolidated Yearly Report Of Medical Only Cases
Georgia/Workers Comp/ -
Application For Permit To Write Insurance
Georgia/Workers Comp/ -
Annual Insurer Update
Georgia/Workers Comp/ -
Petition For Medical Treatment
Georgia/6 Workers Comp/ -
Associate Assessment Affidavit
Georgia/Workers Comp/ -
Annual Premium Writing Report
Georgia/Workers Comp/ -
Annual Report Of Self-Insurers Payroll
Georgia/Workers Comp/ -
Renewal Rehab Supplier Registration
Georgia/Workers Comp/ -
New Rehab Supplier Registration
Georgia/Workers Comp/ -
WC-MCO Panel (Spanish)
Georgia/Workers Comp/ -
Petition For Appointment Of Temporary Conservator For Legally Incapacitated Adult
Georgia/Workers Comp/ -
Notice Of Change Of TPA Servicing Agent
Georgia/Workers Comp/ -
Authorization And Consent To Release Information
Georgia/Workers Comp/ -
Petition For Medical Treatment
Georgia/6 Workers Comp/ -
Petition For Appointment Of Temporary Guardianship Of Minor
Georgia/Workers Comp/
Form Preview
Contact Us
Success: Your message was sent.
Thank you!