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State of California, Division of Workers Compensation REQUEST FOR AUTHORIZATION DWC Form RFA Attach the Doctor s First Report of Occupational Injury or Illness, Form DLR 5021, a Treating Physician
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How to fill out final dwc form rfadoc
How to fill out final DWC form RFADoc:
01
Start by accessing the official website of the relevant workers' compensation board or agency in your jurisdiction.
02
Look for the "Forms" or "Claims" section on the website and locate the final DWC form RFADoc.
03
Download the form onto your computer or print it out if you prefer a hard copy.
04
Begin by filling in your personal information, such as your full name, contact details, and social security number.
05
Provide details about your employer, including their name, address, and contact information.
06
Indicate the date of your injury or illness and provide a brief description of what happened.
07
If you've already received medical treatment for your condition, provide the name and contact information of your healthcare provider.
08
Explain the nature of your injury or illness, detailing the body part affected and how it has impacted your ability to work.
09
Fill in the section regarding your employment status, including your job title, wage rate, and average weekly earnings.
10
Indicate if you have any dependents who rely on your income for support.
11
If you are receiving or have received any other compensation or benefits related to your injury or illness, provide the necessary details.
12
Sign and date the form, certifying that the information you provided is accurate to the best of your knowledge.
13
Make a copy of the completed form for your records before submitting it to the appropriate workers' compensation board or agency.
Who needs final DWC form RFADoc?
01
Employees who have sustained a work-related injury or illness may need to fill out the final DWC form RFADoc.
02
Employers are required to provide this form to their employees for them to complete and submit when filing a workers' compensation claim.
03
Healthcare providers may also need to fill out sections of the form if they have treated the injured or ill employee.
Please note that the specific requirements for filling out the final DWC form RFADoc may vary depending on your jurisdiction. It's essential to consult the instructions provided with the form or seek guidance from your employer or legal counsel.
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