
WORKER'S COMPENSATION COMMISSION
Department of Labor * Government of Guam * P.O. Box 9970 Tamuning, Guam 96931
Tel: (671) 300-4571/77 Fax: (671) 475-6811
WCC File#
INSTRUCTIONS: This side of the form should be completed in full. It authorizes a physician (duly qualified physicians include surgeons,
osteopathic acupuncturists within the scope of their practice as defined by law) to examine and/or treat the employee for the injuries arising out of
such accidental occupational injury, illness, or disease covered by the Guam Worker's Compensation Law. PLEASE TYPE OR PRINT LEGIBLY.
1. Name of Authorized Physician: 2. Name of Medical Facility:
Physician on Duty at GMHA
Guam Memorial Hospital Authority
3. Physician's Address: 4. Medical Facility's Address:
Same as box 4
850 Gov Carlos Camacho Road
Tamuning, Guam 96911
5. Name of Injured Employee , DoB, & SSN: 6. Occupation: 7. Date of Injury:
8. Description of Injury:
9. YOU ARE AUTHORIZED TO PROVIDE MEDICAL SERVICES TO THE EMPLOYEE AS FOLLOWS: (Please check one)
A) If you believe the condition is related to the injury, furnish office and/or hospital treatment as necessary for the effects
of the injury.
B) If there is doubt as to whether the condition is related to the injury, you are authorized to examine the employee, using
indicated non-surgical diagnostic studies, and should promptly advise those listed in Item 14 whether you believe the
disability is due to the alleged injury. Pending further advice, you may provide such necessary conservative treatment.
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C) Other: EXAMINATION & TREATMENT of INJURY(IES) AS STATED IN BOX 8 – SINGLE VISIT ONLY.
****** AUTHORIZATION INVALID IF ALTERED WITHOUT PRIOR APPROVAL BY WCC OFFICE ***********************
YOU ARE REQUESTED TO SUBMIT A WRITTEN REPORT OF FIRST TREATMENT WITHIN 20 DAYS TO THE COMMISSIONER AT THE ADDRESS
INDICATED ITEM 13 BELOW. (See back of this form for instructions as to the medical report and the submission of your charges). Reports are
requisite if services are to be paid.
22 GCA §9132 “Any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or
payment under this Title, or for the purpose of evading liability for any benefit or payment under this Title, shall be guilty of a misdemeanor.”
10. Signature and Title of Authorizing Official: 11. Name and Address of Employer:
12. Date:
13. Send your REPORT to:
14. Name & address of Insurance Carrier to whom COPY of your report and BILL are to be sent:
WORKER'S COMPENSATION COMMISSION
P.O. Box 9970
Tamuning, Guam 96931
See Box 13
FOR STATISTICAL PURPOSES ONLY:
Employee’s ethnicity (please choose one): Employee’s citizenship (please choose one):
Yapese Pohnpeian American
Korean
Chuukese Marshalls Pacific Islander
Chinese
Kosraean Palauan Filipino
Japanese
Other (specify):
U.S.
Permanent Alien Resident
Other (specify):
FORM GWC-101a: AUTHORIZATION for MEDICAL EXAMINATION and/or TREATMENT (Revised 3/2014)