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