DWC Form RFA PDF – Request for Authorization
DWC Form RFA PDF
A DWC form RFA is a legal document often required in the California workers’ compensation system. It is used by the healthcare provider for medical treatment approval of an injured worker. A healthcare provider submits this form to the insurance carrier to ensure the proposed treatment complies with medical guidelines.
You must complete this form accurately to avoid delays in medical services to the injured workers. Fortunately, you can obtain this fillable form by clicking the download button below. Moreover, we will guide you on how to complete this form accurately, its purpose, and additional details to avoid rejection or delays in medical services.

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What is the DWC RFA Fillable Form Purpose?
The state of California requests this form for various purposes for legal compliance and ensure the medical treatment of the injured workers. In addition, the following scenarios will help to understand its purposes.
Streamline Treatment Request
The standard format of this form helps in requesting authorization for medical treatment. The information about the patient and physician understand the nature of the accident.
Ensuring Compliance
This form ensures legal compliance with the Division of Workers Compensation regulation for authorized medical treatment procedures. This form also aligns with the Medical Treatment Utilization Schedule (MTUS).
Facilitating Communication
This form ensures communication stability to enhance the understanding between healthcare providers and insurance carriers for the claim process. It helps reduce misunderstandings and errors.
Documenting Requests
The accurate information on this paper trail helps approval of treatment requests and disputes or appeals.
How To Download DWC California Request for Authorization (Medical Treatment) Form?
Visit Forms Dude
- You must type www.formsdude.com in the Google web browser.
- Press the DWC Forms at the menu bar and explore this form.
- Also, type the form’s name (DWC Form RFA) in the search bar and press enter.
- Click the download button to save it immediately.
- You can also fill out this form here and press the print button for an instant printout.
Step-by-Step Instructions for Filling DWC Form RFA California
The following step-by-step instructions will help you to understand and fill out this form with accuracy:
1- Employee Information
Write the employee’s full name (First, Middle, and Last), date of injury (DD/MM/YYYY), date of birth, claim number, and employer’s name.
2- Requesting Physician’s Information
In this section, write the physician’s name, practice name, address, zip code, phone number, speciality, email address, fax number, and NPI number.
3- Claims Administrator’s Information
In this section, write the company’s name, contact name, address, fax number, zip code, contact number, state, and email address.
4- Requested Treatment
The physician will inform about the treatment plan including diagnosis, ICE-Code, service, CPT Code, and other information. Also, get the physician’s signature with the date.
5- Claims Administrator/ URO Response
In this section, write the authorization number, authorized agent’s name, phone number, fax number, and email address. Also, get the signature with the date.
6- Instructions
You must read the instructions on page 2 to understand the purpose of this form and the eligibility criteria to request for authorization medical treatment in California.
Additional Details to Consider While Filling Out DWC Form RFA
You must ensure these additional details to considered while filling out this form to reduce disputes between healthcare providers and insurance providers:
Be Specific and concise
The information on this form must be concise and specific to describe the need for treatment by providing CPT codes.
Provide Evidence
You must attach all related documents, such as medical reports, clinical guidelines, and test results for a seamless request process.
Follow Guidelines
You must ensure transparent communication to follow the guidelines for better treatment requests. These guidelines must collaborate with MTUS for quick understanding.
Track Submission
The patient file records must be kept in supervision to provide reference. These records include forms, timestamps, and receipts.
FAQs
What is the DWC Form RFA?
This form is a standard document often required in the Division of Workers Compensation to request authorization for medical treatment in California.
What Information is Required in the DWC RFA?
This form contains information about the injured worker’s condition, treatment duration, medical justification, and requested treatment.
Can the Injured Worker Submit a DWC RFA?
No, an injured worker can only request the healthcare provider to fill and submit this form on his behalf.
Where Can I Find a Blank DWC RFA Form?
Fortunately, you can visit the Forms Dude website, search for this form, and click the download button to save a blank fillable form immediately. In addition, you can fill out this here and get an instant printout.