Form Pr-2 - Primary Treating Physician'S Progress Report (Pr-2) Sample Page 6
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8State of California, Division of Workers’ Compensation
REQUEST FOR AUTHORIZATION
DWC Form RFA
Attach the Doctor’s First Report of Occupational Injury or Illness, Form DLSR 5021, a Treating Physician’s Progress Report, DWC Form PR-2, or
equivalent narrative report substantiating the requested treatment.
New Request
Resubmission – Change in Material Facts
Expedited Review: Check box if employee faces an imminent and serious threat to his or her health
Check box if request is a written confirmation of a prior oral request.
Employee Information
Name (Last, First, Middle): CARTER, LINDA J.
Date of Injury (MM/DD/YYYY): 04/11/2012
Date of Birth (MM/DD/YYYY): 01/22/1972
Claim Number: 1000-11
Employer: DC UNIVERSE
Requesting Physician Information
Provider Name: BRUCE WAYNE, M.D.
Practice Name: AVENGERS MEDICAL CENTER
Contact Name: PENNY MONEY
Address: 1111 FOREST AVENUE, SUITE 1111
City: SAN JOSE
State: CA
ZIP Code: 95101
Phone: (408) 555-0133
Fax Number: (408) 555-0166
Provider Specialty: ORTHOPEDIC SURGERY
NPI Number: 111-222-33-44
E-mail Address:
Claims Administrator Information
Claims Administrator Name: KAL-EL
Contact Name: THOR ODINSON
Address: P.O. BOX 111
City: SANTA ROSA
State: CA
ZIP Code: 95401
Phone: (707) 555-0167
Fax Number: (707) 555-0168
E-mail Address:
Requested Treatment (see instructions for guidance; attached additional pages if necessary)
List each specific requested medical services, goods, or items in the below space or indicate the specific page number(s) of the attached
medical report on which the requested treatment can be found. Up to five (5) procedures may be entered; list additional requests on
a separate sheet if the space below is insufficient.
ICD Code
Service/Good Requested
CPT/HCPC Code
Other Information: (Frequency,
Diagnoses (Required)
(Required)
(Required)
(If known)
Duration Quantity, Facility, etc.)
Shoulder impingement;
Thoracic outlet syndrome;
726.2;
Carpal tunnel syndrome;
353.0;
Brachial plexus lesion; Cervical
354.0;
disc herniation; Status post
353.0;
Eight visits of aquatic therapy to
left-sided L3-4, L4-5
722.0;
the cervical and lumbar spine at
laminectomy/microdiscectomy
Aquatic therapy
V45.89;
a frequency of two times a
surgery, 05/04/13; Lumbar
724.2;
week for four weeks
spine post-surgical pain; L3-4,
722.10;
L4-5 and L5-S1 herniated
724.6;
nucleus pulposus and
722.52
instability; L5-S1 degenerative
disc disease
Requesting Physician Signature: __________________________
Date: 01/12/2015
Claims Administrator/Utilization Review Organization (URO) Response
Approved
Denied or Modified (See separate decision letter)
Delay (See separate notification of delay)
Requested treatment has been previously denied
Liability for treatment is disputed (See separate letter)
Authorization Number (if assigned):
Date:
Authorized Agent Name:
Signature:
Phone:
Fax Number:
E-mail Address:
Comments:
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