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If faxed please attach a copy with the fax transmission date stamp. 3 Did you request authorization for medical treatment using DWC Form RFA Request for Authorization for Medical Treatment YES NO If NO please resubmit request using DWC Form RFA. SPRENKLE GEORGARIOU LLP P. O. BOX 3500 SALINAS CA 93912-3500 831 449-8011 phone 831 449-2201 fax TREATMENT/MEDICATION DENIAL FORM PART I - TO BE COMPLETED BY CLIENT/PATIENT 1 Name of Client/Patient 2 Name and Address of Insurance Company Phone 3 Date...

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