Get Wc 104 Ga Form

The WC 104 GA Form is an important document for notifying employees of their medical release to return to work with restrictions or limitations. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to complete the WC 104 GA Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the Board Claim Number at the top of the form. This number is essential for tracking purposes.
3. Enter the employee's last name, first name, and middle initial in the designated fields to identify the individual associated with the claim.
4. Provide the Social Security Number or Board Tracking Number to further specify the claim and employee details.
5. Include the date of the injury, ensuring that this information is accurate to avoid any processing issues.
6. In section A, input the county of injury where the incident took place, as well as the name and contact information for the insurer or self-insurer.
7. Fill out the employer's information, including the name, address, city, state, zip code, and phone number, ensuring that it matches official records.
8. Section B contains important notices. Specify the authorized treating physician's name and the date they released the employee to work with restrictions.
9. List out the limitations provided by the physician in the appropriate field, making sure to detail any restrictions clearly.
10. Attach the physician's report that authorizes the employee's release and describes their limitations. Ensure this document is included with the submission.
11. Indicate the change in income benefits, specifying the previous amount and the reduced amount after the release to work with restrictions.
12. The employer representative is required to certify the completion of this form by printing their name, signing, and including their contact information.
13. Once all fields are filled out, review the document for accuracy. You may then save the changes, download, print, or share the form as required.

Take the necessary steps to fill out and file the WC 104 GA Form online today.