WebMedical mileage expense form. If you need a medical mileage expense form for a year not listed here, please contact the Information and Assistance Unit at your closest district office of the Workers’ Compensation Appeals Board. Form name. Medical mileage expense form - English/Spanish. * For travel on or after 1/1/23. WebDWC Form RFA (Version 12/2012) 1 State of California Division of Workers’ Compensation . Request for Authorization for Medical Treatment (DWC Form RFA) To accompany the Doctor’s First Report of Occupational Injury or Illness, Form DLSR 5021, a Treating Physician’s Progress Report, DWC Form PR-2, or narrative report …

State of California Division of Workers’ Compensation …

WebDec 1, 2014 · In the top box of the form, check the reason for the RFA. Check “New Request” for all treatment that you have not previously requested. Check “Resubmission – Change in Material Facts” if new information is available about the employee’s medical condition. Check “Expedited Review: Check box if employee faces an imminent and … WebRequirements Parts of the California Code of Regulations (CCR) dictate how you request authorization for treatment. Simply put, you must: Make your request in writing for a … grams of fiber in bell pepper

California Code of Regulations, Title 8, Section 9792.6

WebDivision of Workers' Compensation Request for Authorization for Medical Treatment (DWC Form RFA) To accompany the Doctor's First Report of Occupational Injury or Illness, Form DLR 5021, a Treating Physician's Progress Report, DWC Form PR-2, or narrative report substantiating the requested treatment. WebDivision of Workers' Damages - Injured worker data. Cal/OSHA - Shelter & Health WebMedical mileage expense form. If you need a medical mileage expense form for a year not listed here, please contact the Information and Assistance Unit at your closest district … chinatown hotel west 22nd place chicago il