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Article Structure

Common mistakes

  1. Incomplete Identifying Information: Failing to fill out all sections, such as the employee's last name, first name, and social security number, can lead to delays in processing.

  2. Incorrect Dates: Not providing the correct date of injury or the date of the medical release can cause confusion and may affect the employee's benefits.

  3. Missing Attachments: Forgetting to attach the physician's medical report that outlines the restrictions or limitations can invalidate the form.

  4. Failure to Notify: Not sending a copy of the form to the employee and their counsel within the required 60 days can lead to compliance issues.

  5. Incorrect Benefit Calculation: Miscalculating the reduction in income benefits can result in overpayments or underpayments, which may create legal complications.

  6. Signature Errors: Not signing the form or providing an incorrect name can render the document invalid and delay the employee's return to work.

Essential Points on This Form

What is the purpose of the Georgia WC-104 form?

The Georgia WC-104 form serves as a notification to employees that their authorized treating physician has cleared them to return to work, albeit with certain restrictions or limitations. This form ensures that employees are informed about their medical status and any necessary accommodations that may be required in their workplace. It is a crucial document in the workers' compensation process, helping to facilitate a smooth transition back to work.

Who is responsible for completing and sending the WC-104 form?

The employer is responsible for completing the WC-104 form. They must send it to the employee and, if applicable, the employee’s legal counsel. This notification must occur within 60 days of the physician’s release to return to work. Timely communication is essential to comply with Georgia's workers' compensation laws.

What information is included in the WC-104 form?

The WC-104 form includes identifying information about the employee, such as their name, Social Security number, and date of injury. It also contains details about the employer and insurer, as well as specific information regarding the medical release, including any restrictions or limitations set forth by the physician. A copy of the physician's report is typically attached to this form.

What happens if an employee is released to work with restrictions?

If an employee is released to work with restrictions, their income benefits may be adjusted. The WC-104 form will specify the new benefit amount, which will be reduced unless the employee returns to work earlier than the date indicated. This adjustment reflects the change in the employee's work status and is an important aspect of managing their benefits during recovery.

Can the WC-104 form be filed with the Georgia State Board of Workers' Compensation?

The WC-104 form itself is not directly filed with the Georgia State Board of Workers' Compensation. Instead, it is used as an attachment to a Form WC-2 when converting benefits from Temporary Total Disability (TTD) to Temporary Partial Disability (TPD). This ensures that the Board has all necessary documentation regarding the employee’s return to work and any associated changes in benefits.

What should an employee do if they have questions about the WC-104 form?

If an employee has questions regarding the WC-104 form or their workers' compensation benefits, they should contact the State Board of Workers’ Compensation. They can reach out via phone at 404-656-3818 or 1-800-533-0682. Additionally, employees can visit the Board's website for more information and resources related to their situation.

What are the consequences of providing false information on the WC-104 form?

Providing false information on the WC-104 form is a serious offense. Willfully making a false statement to obtain or deny benefits can lead to penalties of up to $10,000 per violation. This emphasizes the importance of honesty and accuracy when completing any documentation related to workers' compensation claims.

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Georgia Wc 104 Sample

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

 

 

INSURER/

Name

 

 

EMPLOYEE

 

 

 

 

 

 

 

 

 

SELF-INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

Name

 

 

 

 

 

 

CLAIMS OFFICE

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

Address

 

 

 

 

 

 

 

 

 

 

E-mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

 

Name

 

 

 

 

 

 

EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

SBWC ID# (five digit no.)

 

Insurer/Self-Insurer File #

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

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-104

REVISION . 07/2011

104

NOTICE TO EMPLOYEE OF MEDICAL RELEASE TO

RETURN TO WORK WITH RESTRICTIONS OR LIMITATIONS

Key takeaways

Here are key takeaways about filling out and using the Georgia WC 104 form:

  • The WC 104 form is used by employers to notify employees about their medical release to return to work with restrictions.
  • Employers must send this form, along with the attached medical report, to the employee and their legal counsel within 60 days of the release.
  • This form should only be filed with the Board as an attachment to a Form WC-2 when converting benefits from Temporary Total Disability (TTD) to Temporary Partial Disability (TPD).
  • The form includes identifying information such as the employee's name, date of injury, and the insurer's details.
  • Employers must include specific limitations provided by the authorized treating physician regarding the employee's ability to work.
  • Failure to accurately complete the form or provide false information can result in penalties of up to $10,000.

Document Characteristics

Fact Name Fact Description
Purpose The WC-104 form notifies employees of their medical release to return to work with restrictions or limitations.
Governing Law This form is governed by O.C.G.A. §34-9-104(a) and Board Rule 104.
Submission Timeline Employers must send this form to the employee within 60 days of the physician's release.
Attachment Requirement A medical report must be attached to the WC-104 when it is sent to the employee.
Benefit Conversion The form is filed with the Board as an attachment to Form WC-2 when converting benefits from TTD to TPD.
Income Benefits Income benefits may be reduced if the employee returns to work with restrictions.
Non-Catastrophic Injuries The form specifies that the injury is not considered catastrophic under O.C.G.A. §34-9-200.1(g).
Employer's Certification The employer must certify that they have sent a copy of the form to the employee and their counsel.
Contact Information Employees can contact the State Board of Workers’ Compensation for questions at 404-656-3818 or 1-800-533-0682.
False Statements Penalty Making false statements to obtain or deny benefits can result in penalties of up to $10,000 per violation.