DWC Form RFA, Request for Authorization

What is the DWC RFA form?

The DWC RFA Request for Authorization form is the form required by the employee's primary care physician to initiate the user verification process required by Section 4610 of the Labor Code.

What is DWC Form RFA used for?

The california rfa form is used to request authorization for treatment that is reasonably necessary to treat or alleviate a work injury or illness.

How do I complete the DWC RFA form?

The dwc form rfa must include:

• Employee name, address, phone number, and social security number
• Employer's name, address, phone number, and application number.
• Name, address, phone number, and license number of the attending physician.
• Date of the first examination of the injured worker by the attending physician.
• Date of injury
• Description of the condition of the injured worker
• Suggested course of treatment
• Expected duration of treatment
• Estimated cost of treatment

How do I submit a DWC RFA form?

The rfa form dwc must be filed with the claims administrator within 30 days of the date the treating physician first saw the injured worker.

Who must sign the DWC RFA?

The dwc rfa form must be signed and dated by you, and your healthcare provider must sign and date the RFA. Your signature indicates that you, as the affected worker, have received a copy of the RFA.