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WC-104 NOTICE TO EMPLOYEE OF MEDICAL RELEASE TO RETURN TO WORK WITH RESTRICTIONS OR LIMITATIONS GEORGIA STATE BOARD OF WORKERS COMPENSATION 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.
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How to fill out wc 104 ga form
How to fill out WC 104 GA form:
01
Start by providing your personal information in the designated fields. This includes your name, address, phone number, and Social Security Number.
02
Next, fill in your employer's information. Include the employer's name, address, and contact details.
03
Provide the date and time of the accident or injury occurrence.
04
Describe the nature of the accident or injury in detail. Include information such as the location, cause, and any contributing factors.
05
If there were witnesses to the accident, include their names and contact information.
06
Indicate the body part(s) affected by the injury and specify the type of injury sustained.
07
If you sought medical treatment for the injury, include the name and contact details of the healthcare provider or facility.
08
Specify whether you missed work as a result of the injury and provide the dates of absence.
09
If you received any compensation or benefits related to the injury, such as sick leave pay or disability benefits, provide the necessary details.
10
Sign and date the WC 104 GA form.
Who needs WC 104 GA form?
01
Employees who have sustained a work-related injury or illness that requires medical treatment or results in missed work may need to complete WC 104 GA form.
02
Employers may need this form to accurately report and document workplace injuries for insurance and legal purposes.
03
Insurance companies and workers' compensation boards may require WC 104 GA forms to process and evaluate claims for compensation and benefits related to work-related injuries or illnesses.
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