WC-104 NOTICE TO EMPLOYEE OF MEDICAL RELEASE TO RETURN TO WORK WITH RESTRICTIONS OR LIMITATIONS GEORGIA STATE BOARD OF WORKERS' COMPENSATION NOTICE TO EMPLOYEE OF MEDICAL RELEASE TO RETURN TO WORK WITH RESTRICTIONS OR LIMITATIONS Instructions: The employer shall use this form to notify an employee that the authorized treating physician has released the employee to return to work with restrictions or limitations, as required by O.C.G.A. §34-9-104(a) and Board Rule 104. This form, with attached medical report, must be sent to the employee and counsel for the employee, within 60 days of the release to return to work. This form, along with attached medical report, should only be filed with the Board as an attachment to a Form WC-2 when converting benefits from TTD to TPD. Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION County of Injury Name INSURER/ SELF-INSURER EMPLOYEE Name Address CLAIMS OFFICE City State Zip Code Address E-mail City State Zip Code SBWC ID# (five digit no.) Insurer/Self-Insurer File # Name EMPLOYER Address City State Zip Code Phone Number E-mail E-mail B. NOTICE TO EMPLOYEE 1. Your injury, which occurred on or after July 1, 1992, is not catastrophic, as defined in O.C.G.A. 34-9-200.1(g). 2. You are receiving income benefits, and are not working. 3. Your authorized treating physician, who is has released you to work with restrictions or limitations on 4. The limitations from the physician are as follows: A copy of the physician's report, which authorizes your release and describes your limitations, is attached. 5. Because you have been released to return to work with restrictions, your income benefits will be reduced from $ per week to $ per week on , unless you return to work at an earlier date. I certify that I have today sent a copy of this form with the attached medical report to the employee and counsel for the employee, if represented. Print Name Date Signature Phone Number and Ext Employer / Insurer E-mail -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-104 REVISION . 07/2011 104 NOTICE TO EMPLOYEE OF MEDICAL RELEASE TO RETURN TO WORK WITH RESTRICTIONS OR LIMITATIONS American LegalNet, Inc. www.FormsWorkFlow.com