How to Complete the California DWC Form RFA: Request for Authorization

To complete the California DWC Form RFA, the treating physician fills in the employee and claims administrator identifying information, checks the correct type of review, lists each specific treatment being requested with a brief clinical justification, signs the form, and transmits it with recent supporting medical records to the claims administrator’s designated utilization review channel. The form is a free PDF on the Division of Workers’ Compensation website and can be sent by fax, mail, or email.¹

Where to Download the Form

The DWC Form RFA is available as a free PDF on the Division of Workers’ Compensation forms page at dir.ca.gov/dwc/forms.html.² The form is titled “Request for Authorization” and carries a revision date of 01/2014, though the regulatory requirements around its use have been updated since. Filling the PDF out digitally and then printing it for signature usually produces a cleaner submission than handwriting the fields.

What to Gather Before You Start

Incomplete submissions are one of the most common reasons requests stall. If the claims administrator receives an RFA without adequate supporting documentation, the utilization review clock may not start running until the missing records arrive. Before you touch the form, have these in front of you:

The employee’s full name, date of birth, and the claim number assigned by the claims administrator.
The date of injury linking the treatment request to the workplace incident.
The ICD-10 diagnostic codes for the condition and the proposed treatment.
The claims administrator’s name, mailing address, and the fax number or email designated specifically for utilization review submissions (not a general office number).
Recent progress notes, imaging, lab results, or other documentation establishing medical necessity. This supporting documentation must be no more than 30 days old at the time of the request.³

Filling Out Each Section

Physician and Claims Administrator Information

The top portion of the form captures identifying details for both sides: the requesting physician’s name, practice address, phone, fax, and email, plus the same contact fields for the claims administrator. The fax number is the field to double-check, because fax is still the primary channel most claims administrators use to send the decision back.

Type of Review

Check the box that matches the clinical situation:

Prospective — treatment that has not yet been provided. This covers the usual case: requesting authorization before a surgery, a course of physical therapy, or advanced diagnostics.
Concurrent — treatment already underway that needs continued authorization, such as an extended hospital stay or additional therapy sessions on an existing regimen.
Retrospective — treatment that has already been provided, typically because the care was emergent or prior authorization was not obtained.
Expedited — a request where the standard review timeline would pose an imminent and serious threat to the employee’s health, including severe pain, potential loss of life or limb, or significant deterioration. The requesting physician must certify the need for expedited review in writing and document the medical basis on the form. If the claims administrator later determines the expedited request isn’t supported by evidence of an imminent threat, it reverts to the five-business-day prospective timeline.⁴

Requested Treatment and Clinical Justification

In the treatment section, list each specific service being requested. Name the procedure, therapy, medication, or equipment, along with the frequency and duration where applicable. Each line needs a short clinical justification tying it to the diagnosed condition.

Vague language invites modification or denial. “Physical therapy as needed” gives the reviewer nothing to evaluate. Something like “12 sessions of physical therapy, 3 times per week for 4 weeks, to restore shoulder range of motion following rotator cuff repair” gives the reviewer a concrete request measured against a concrete clinical goal. Frame the justification around the condition, the functional deficit, and what the treatment is expected to accomplish.

Signature

The treating physician must sign the form. An unsigned form is incomplete and does not start the utilization review clock. Electronic signatures are permitted only if the claims administrator has agreed to accept them.³ Without that agreement in place, use a wet signature.

When a Narrative Report Can Substitute

In some cases a claims administrator will accept a detailed narrative medical report in place of the DWC Form RFA. This is not automatic; the claims administrator has to voluntarily agree to it. If they do, the narrative must still include all the essential information: employee and provider identification, the specific treatments listed on the first page, substantiating documentation no older than 30 days, and the physician’s signature.³ When in doubt, use the actual form. It eliminates any dispute over whether the request was properly submitted.

How to Submit the Completed Form

Send the signed form along with all supporting medical documentation to the claims administrator’s utilization review department by fax, mail, or email.¹ Fax is the most common method because the confirmation report produces a timestamp, and that timestamp is what starts the decision clock.

If you fax or email the form, the cover sheet or transmission must include the date, time, and place of transmission along with the fax number or email address to which the form was sent.⁵ Keep the fax confirmation report or email delivery receipt. If a dispute later arises over whether the request was received on time, that record is the evidence.

Watch the time of day. A form faxed after 5:30 PM Pacific Time is treated as received the next business day. Expedited and concurrent requests are the exception: they’re deemed received at the actual time of transmission regardless of when they arrive.⁵

What Happens After You Submit

Once the claims administrator has a complete form, California law gives them a limited window to respond:

Prospective or concurrent review: a decision within five business days of receipt. The date of receipt (if before 5:30 PM) counts as day zero, and the next business day is day one. Saturdays, Sundays, and holidays don’t count.⁶
Expedited review: a decision within 72 hours of receipt.⁴
Retrospective review: a decision within 30 days of receiving the request and the medical information reasonably necessary to decide.⁷

If the claims administrator can’t decide within the applicable deadline because it needs more information, test results, or expert consultation, it must immediately notify the physician and the injured worker in writing, explaining what is missing and when a decision is expected.⁸ The clock pauses until the requested information arrives, at which point the original timeline restarts.

The decision itself will take one of four forms: approval, modification (some of what was requested, with written clinical reasoning), denial (with citation to the specific medical evidence or guideline provisions), or delay (with written notice of what’s missing). For denials and modifications, the initial communication may come by phone, fax, or email, but a written follow-up is mandatory and must explain the clinical basis for the decision. That written denial letter is also the document that starts the clock for the injured worker to appeal through Independent Medical Review, which has its own form and a 30-day filing window.⁹

1
State of California Department of Industrial Relations. Division of Workers’ Compensation Request for Authorization DWC Form RFA
2
California Department of Industrial Relations. DWC Forms
3
California Department of Industrial Relations. DWC Provides Clarification on Use of Request for Authorization Form
4
Department of Industrial Relations. California Code of Regulations Title 8 Section 9792.9.3 – Utilization Review Timeframes
5
Legal Information Institute. California Code of Regulations 8 CCR 9792.9.1 – Utilization Review Standards Timeframe Procedures and Notice
6
Division of Workers’ Compensation. Answers to Frequently Asked Questions About Utilization Review for Claims Administrators
7
Department of Industrial Relations. California Code of Regulations Title 8 Section 9792.9.1 – Utilization Review Receipt of Request for Authorization
8
California Legislative Information. California Labor Code Section 4610
9
Department of Industrial Relations. Answers to Frequently Asked Questions About Independent Medical Review