CLEAN COPY DWC Form RFA - California Department of ...
REQUEST FOR AUTHORIZATION DWC Form RFA Attach the Doctor’s First Report of Occupational Injury or Illness, Form DLSR 5021, a Treating Physician’s ... List each specific requested medical services, goods, or items in the below space or indicate the specific page number(s) ... Other Information: (Frequency, Duration Quantity, etc.) ................
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