WC-200b REQUEST / OBJECTION FOR CHANGE OF PHYSICIAN / ADDITIONAL TREATMENT GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST / OBJECTION FOR CHANGE OF PHYSICIAN / ADDITIONAL TREATMENT Instructions: When you receive this complete form, you must file a response with the Board within 15 days of the date on the certificate of service (O.C.G.A. 9-11-6 (e)). All responses must be filed on Form WC-200b Board Claim No. Employee Last Name Employee First Name M.I. Date of Injury SSN or Board Tracking # A. IDENTIFYING INFORMATION County of Injury Name of counsel (if represented) EMPLOYEE Address City State Name Name of counsel (if represented) Name INSURER / SELF-INSURER Zip Code Claim Office Address CLAIMS OFFICE E-mail Address SBWC ID# (five digit no.) City State Zip Code B. PHYSICIANS / TREATMENT 1. The currently authorized treating physician is Dr.: Address Name City 2. Authorization is requested for: State Zip Code Address a Change of Physician to additional treatment City State Zip Code Name C. ACTION REQUESTED This action is being requested by: Employee Employer Insurer 1. A request is being made for change of primary treating physician to Dr. 2. A request is being made for additional medical treatment to be provided by Dr. The current authorized primary treating physician shall remain authorized. 3. An objection is being filed by: Employee Employer Insurer This request / objection is based upon the following (attach supporting documentation): Proximity of physician's office to employee's residence Accessibility of physician to employee Necessity for specialized care Language barrier Referral by authorized physician Panel of physicians Other: See Board Rule 200 (b) (2) Excessive/redundant performance of medical procedures Noncompliance by physician with Board Rules and procedures Number of physicians who have treated the employee Prior requests for change of physician or treatment Employee released to normal duty work by current authorized physician Duration of treatment without appreciable improvement Current physician indicates nothing more to offer WC/MCO internal dispute resolution process (procedure attached) D. ENTRY OF APPEARANCE I hereby certify to the existence of a valid fee contract in compliance with Board Rule 108 or Form WC 102B filed in compliance of Board Rule 102. (fee contract or Form WC 102B has been filed previously or is attached). E. CERTIFICATE OF SERVICE I hereby certify that the parties have made a good faith effort to reach agreement on this issue, but have failed to do so to date. I further certify that I have this day sent a copy of this form with supporting documentation to the State Board of Workers’ Compensation and to all parties and counsel in this claim. Print Name Here Phone Number Address Signature Date City E-mail State Zip Code 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-200b REVISION . 07/2011 200b REQUEST / OBJECTION FOR CHANGE OF PHYSICIAN / ADDITIONAL TREATMENT American LegalNet, Inc. www.FormsWorkFlow.com