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Request for authorization letter

Treatment request medical form 2026

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The document is a Request for Authorization (DWC Form RFA) used in California's workers' compensation system. It allows a treating physician to initiate the utilization review process for medical treatment by submitting necessary information about the employee, including personal details, diagnosis, requested treatments, and supporting documentation. The form includes options for new requests or resubmissions and requires signatures from both the requesting physician and claims administrator. It outlines the process for approval or denial of treatment requests.

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Click ‘Get Form’ to open the treatment request medical form in the editor.
Begin by checking the appropriate box at the top of the form to indicate whether this is a new request or a resubmission due to changes in material facts.
Fill in the Employee Information section, including the name, date of injury, date of birth, claim number, and employer details.
Complete the Requesting Physician Information section with your name, practice name, contact details, specialty, and NPI number.
In the Claims Administrator Information section, provide all necessary contact information for the claims administrator.
List each specific requested treatment in the Requested Treatment section. Ensure you include diagnosis, ICD code, service/good requested, and CPT/HCPCS code if known.
Sign and date at the bottom of the form to validate your request before submission.

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