Overview: The Request for Authorization for Medical Treatment (DWC Form RFA) is required for the employee's treating physician to initiate the utilization ...

This page of the form must be completed in full, and authorizes a physician of the employee's choice (*See item below) to examine and/or treat an employee, ...

I authorize the medical provider to provide initial medical treatment to the employee named above. Signature: Date: Name: Position / Title:

The employer accepts responsibility and authorizes initial treatment, including diagnostic testing, for the employee listed above.

○ Form CA-16 is valid for up to sixty days from date of issuance, and may be terminated earlier upon written notice from OWCP to the provider. It should not ...

This form authorizes a health care provider to treat the following Edustaff Employee: for a work related injury that occurred on ...

If employee requests medical treatment, supervisor completes the Worker's Compensation Treatment Authorization form and gives it to the injured employee.

Please be advised the following employee is authorized to receive initial care for an injury or illness the employee reports having received on-the-job for ...

Submit all charges on CMS 1500 (red form), UB04 form, or accordingly on each state's industrial commission approved form. Please include the claim number, ...

Authorization for Immediate Medical Treatment Employer Instructions: To report injuries, email FirstNotice@icwgroup.com or call 855.442. 9252. Complete this ...