Get Request For Authorization For Medical Treatment (dwc Form Rfa)

The Request For Authorization For Medical Treatment (DWC Form RFA) is an essential document for submitting a request for medical treatment in the workers' compensation system. This guide provides comprehensive and user-friendly instructions on how to fill out the form online.

Follow the steps to complete the DWC Form RFA accurately.

1. Click ‘Get Form’ button to access the form and open it in your online editor.
2. Begin by entering patient information. Fill in the patient's name, date of birth, date of injury, employer name, and claim number in the respective fields provided.
3. Next, fill out the claims administrator information. Input the name of the claims administrator, adjustor name (if known), address, city, state, zip code, telephone number, and fax number.
4. Provide provider information by entering the provider's name, practice name, address, city, state, zip code, telephone number, fax number, provider specialty, state license number, and national provider ID number.
5. In the requested treatment section, clearly state the treatment you are requesting. You may also refer to specific page numbers of accompanying medical reports if necessary. Ensure to attach additional pages if you need more space.
6. Complete the date of request field and have the provider sign the form to validate the request.
7. Review the claims administrator response section, where they can approve the requested treatment, record an approval tracking number (optional), and provide the date the request for authorization was received.
8. The claims administrator or authorized agent will sign the form and include the date of response to the request and their printed name.
9. Once all sections are filled out, save your changes, and you have the option to download, print, or share the completed form as needed.

Ensure your medical treatment request is handled promptly by completing the DWC Form RFA online today.