How to Complete and Submit the DWC Form RFA: Sections, Submission, and Deadlines

The DWC Form RFA is the Request for Authorization that a California treating physician submits to a workers’ compensation claims administrator to get approval for a specific medical service, medication, procedure, or referral tied to a workplace injury. The current PDF is free to download from the Division of Workers’ Compensation, and a properly completed, signed submission with recent supporting records starts a five-business-day clock for the insurer to respond.

Where to Download the Current Form

The form lives on the Division of Workers’ Compensation forms page at dir.ca.gov.¹ The direct file is a PDF titled “Request for authorization for medical treatment.”² Use the current version from this page. Older PDFs you may have saved, or an improvised letter in place of the form, can be returned as incomplete.

What Goes in Each Section

The form is organized around three questions: who is the injured worker, who is the requesting physician, and what treatment is being asked for. Every required field has to be filled before the response deadline starts.

Employee Information

At the top, enter the injured worker’s full name (last, first, middle), date of birth, date of injury, and claim number.² The claim number is assigned by the employer’s insurance carrier and appears on prior correspondence. A missing or wrong claim number can get the request bounced before anyone looks at the medical content.

Requesting Physician Information

Include the treating physician’s name, professional license number, phone, fax, and the address where the claims administrator should send its decision. Office staff can enter these details, but the physician has to personally sign and date the form. An unsigned RFA is not a valid request.²

Requested Treatment

This section is where most RFAs fail. Each requested service, good, or item needs its own line with the diagnosis, the ICD code for that diagnosis, the specific treatment, and the CPT or HCPCS code if known.² “Physical therapy” by itself is not enough. The reviewer needs the number of visits, the body region, and the modality. Vague entries give the utilization reviewer grounds to send the request back.

If the specifics live in an attached medical report rather than on the form itself, write in the exact page numbers of the report where each requested treatment can be found.²

Review Type

Check the box for the kind of review being requested. Prospective review is approval before the treatment is provided and covers most requests. Concurrent review applies when treatment is already underway and the physician needs to continue or extend it. Expedited review applies only when the physician certifies in writing that the worker faces an imminent and serious threat to health, or that waiting the standard five business days would be detrimental to the worker’s condition. The box you check changes which response deadline the claims administrator has to meet. An expedited request that is not backed by evidence of imminent risk will be downgraded to the standard five-business-day timeline.³

Supporting Documentation

The form alone is not enough. Attach a Doctor’s First Report of Occupational Injury or Illness (Form DLSR 5021), a Treating Physician’s Progress Report (DWC Form PR-2), or an equivalent narrative report that substantiates the treatment being requested.² The supporting records must have been created no more than 30 days before you submit. Stale records are an independent reason to return the request as incomplete.⁴

When the RFA Counts as “Complete”

Response deadlines only run once the claims administrator receives a complete RFA. Under California Code of Regulations section 9792.6.1(u), a request counts as complete only when all of the following are true:⁴

The form names both the injured employee and the requesting provider.
All recommended treatments are identified with specificity in the designated section of the form, or on the first page of an attached narrative report.
The supporting medical records were created no earlier than 30 days before submission.
The treating physician signed the form, and it was sent by mail, fax, or encrypted electronic means to the address the claims administrator designated for RFA submissions.

Fail any one of these — a missing signature, a vague treatment description, an outdated report — and the request can be returned without starting the review clock. That is the most common reason treatment gets delayed, and it is avoidable.

How and Where to Submit

Send the completed form to the address, fax number, or email the claims administrator has designated for authorization requests.² That contact information comes from earlier correspondence on the claim; there is no single universal address. For email, the form instructions call for encrypted electronic means, so standard unencrypted email may not qualify.

Fax remains the common method because it produces an immediate transmission confirmation with a timestamp. The date and time the claims administrator receives the completed RFA is treated as “day zero,” and the next business day is day one of the utilization review clock.⁵ Keep the fax confirmation sheet or email delivery receipt. If a dispute later arises about when the request arrived, that proof matters.

Whoever actually sends the fax or email should confirm that every page went through, including each page of the attached medical reports. A partial transmission that drops the supporting documentation can be returned as incomplete.

The Five-Day Window After the First Visit

When treatment is being provided by a medical provider network physician, a health care organization physician, a predesignated physician, or an employer-selected physician, Labor Code section 4610 requires the physician to submit both the first report of injury and a complete RFA within five days of the employee’s initial visit and evaluation.⁶ Missing this window does not automatically bar the request, but it complicates the timeline.

What Happens After You Submit

Once a complete RFA is received, the claims administrator has to issue a decision within deadlines set by California Code of Regulations section 9792.9.3:³

Prospective or concurrent review: five business days from the date of receipt of the completed RFA.
Expedited review: 72 hours after receipt of the information reasonably necessary to make the determination.
Retrospective review: 30 days from receipt of the request.

For counting, if the RFA is received before 5:30 p.m., that day is day zero and the next business day is day one. Saturdays, Sundays, and holidays do not count.⁵

The reviewer can approve the request, modify it, or deny it. The decision is first communicated by phone, fax, or email within 24 hours of being made. Written notice then follows within two business days for prospective decisions, within 24 hours for concurrent decisions, and within 72 hours of receipt of the original request for expedited decisions.⁵ The written notice goes to both the requesting physician and the injured worker.

When an RFA Is Not Required

Not every treatment in the first month after an injury needs prior authorization. For injuries on or after January 1, 2018, emergency treatment and medical care consistent with the Medical Treatment Utilization Schedule guidelines is authorized without prospective utilization review during the first 30 days following the initial date of injury, as long as the treating physician is within the employer’s medical provider network, health care organization, or is a predesignated or employer-selected physician.⁶

Several categories still require an RFA even inside that 30-day window:⁶

Pharmaceuticals that are neither exempt from prospective review nor authorized by the MTUS drug formulary.
Nonemergency surgery, inpatient or outpatient, including pre- and post-surgical services.
Psychological treatment.
Home health care.
Imaging and radiology beyond basic x-rays.
Durable medical equipment with a combined total value over $250.

Drugs not on the MTUS formulary always require an RFA and prospective utilization review, regardless of timing.⁷ When requesting a non-formulary drug, submit the standard RFA and include strong supporting documentation showing which formulary alternatives were tried and why they failed or are contraindicated.

If the Request Is Modified or Denied

When a utilization review decision modifies or denies the requested treatment, the injured worker or their representative can challenge it through Independent Medical Review using DWC Form IMR-1, sent with a copy of the UR determination letter to the address printed on the form. The filing deadline is either 10 or 30 days from the date of the UR determination letter, depending on the circumstances indicated on the application.⁸ Missing that deadline is one of the most common reasons IMR applications are rejected as ineligible, along with missing signatures and incomplete documentation.

1
California Department of Industrial Relations. DWC Forms
2
State of California Department of Industrial Relations. Division of Workers’ Compensation Request for Authorization DWC Form RFA
3
California Department of Industrial Relations. California Code of Regulations Title 8 Section 9792.9.3 – Utilization Review Timeframes
4
California Department of Industrial Relations. California Code of Regulations Title 8 Section 9792.6.1 – Utilization Review Standards Definitions
5
California Department of Industrial Relations. DWC FAQs on UR for Claims Administrators
6
California Legislative Information. California Code LAB 4610 – Utilization Review
7
New York Codes, Rules and Regulations. California Code of Regulations Title 8 Section 9792.9.8 – Utilization Review MTUS Drug Formulary
8
Department of Industrial Relations. Independent Medical Review (IMR)