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Sample WC Forms
Sample DWC Form RFA (02-2014)
Periodically, Workers' Comp releases new forms. An updated form for the State of California Division of Workers' Compensation Request for Authorization for Medical Treatment (a.k.a. DWC Form RFA) was released 02-2014. An RFA form can be generated through the Surgery Tab Action Buttons on the Modify Appointment screen. See sample of a filled-in RFA form.
Effective version 16.02.22, the Requested Treatment section of the RFA includes detailed information pulled from the Diagnosis and Procedure sections of the Surgery Tab.
Sample filled-in RFA form, effective 02-2014:
Updates:
Effective version 16.02.22, the Requested Treatment section of the RFA includes more detailed information pulled from the Diagnosis and Procedure sections of the Surgery tab.
Effective version 14.07.11, the RFA can now display diagnosis codes for which there is no charge. Codes are added to the form via the Surgery Tab on the Modify Appointment screen.
Effective version 14.07.01, the RFA now prints the date of the patients’ appointment instead of the Clinic Date.
Old DWC Form RFA, released 12/2012
