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Ga 200 form pdf 2026
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- Click ‘Get Form’ to open the ga 200 form PDF in our editor.
- Begin by filling in the 'Identifying Information' section. Enter the Board Claim Number, Employee's Last Name, First Name, Middle Initial, SSN or Board Tracking Number, and Date of Injury.
- Next, provide your address details including County of Injury, City, State, and Zip Code in the designated fields.
- In the 'Physicians / Treatment' section, specify the currently authorized treating physician's name and address. Then indicate the new physician for whom authorization is requested.
- Detail any additional treatment authorized by filling in the relevant fields under 'Additional Treatment'.
- In the 'Agreement' section, ensure both parties sign and print their names where indicated. Include necessary contact information.
- Finally, complete the 'Certification' section by signing and dating the form before submitting it to all required parties.
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