Get Rfa Form

Completing the Request for Authorization (Rfa Form) online is a vital step in the process of seeking approval for medical treatment. This guide provides clear, step-by-step instructions to help you navigate the form efficiently.

Follow the steps to complete the Rfa Form online accurately.

1. Press the ‘Get Form’ button to obtain the form and open it in your document editor.
2. Indicate whether this is a new request or a resubmission due to changes in material facts. If expedited review is necessary, check the appropriate box.
3. Fill in the employee information section, including the employee's name, date of injury, and claim number.
4. Complete the provider information section with the provider's name, practice name, address, phone number, and email address.
5. Fill out the claims administrator information, ensuring all contact details are accurate, including the claims administrator's name and relevant addresses.
6. In the requested treatment section, clearly state the treatment needed, or reference the page number of the accompanying medical report that contains this information.
7. Provide the relevant diagnosis, ICD code, and CPT/HCPCS code for the requested treatment.
8. Include any additional information required, such as frequency, duration, quantity, and facility details.
9. Ensure the treating physician's signature and date are entered before submission.
10. Once all fields are completed, save the changes. You may download, print, or share the form as necessary.

Complete your documents online to ensure timely processing of your authorization requests.