A California treating physician uses this form to ask the claims administrator to authorize specific medical treatment, goods or services for an injured worker, which starts utilization review under Labor Code section 4610. Each request lists the diagnosis, ICD code and service, with a Form 5021, PR-2 or narrative report attached as support. The claims administrator or utilization review organization then approves, modifies, delays or denies it.
The requesting treating physician completes the employee, physician, claims administrator and requested treatment sections and must sign; either the primary treating physician or a secondary physician may submit one. The claims administrator or utilization review organization (URO) completes the response block at the bottom of page 1 or answers by separate written notice.
Check New Request or Resubmission for a change in material facts. A resubmission fits only when the facts behind the earlier utilization review decision have changed, and it needs documentation. Check Expedited Review only if the employee faces an imminent and serious threat to his or her health, again with supporting documentation. A separate box marks the form as written confirmation of a prior oral request, which 8 CCR 9785(h) says must be clearly marked at the top.
Enter the employee's name (last, first, middle), date of injury and date of birth in MM/DD/YYYY format, claim number and employer. The instructions say the requesting physician must complete all identifying information for the employee, the claims administrator and the physician, and a request that does not identify the employee is not complete.
Give the physician's name, practice name, contact name, address, phone, fax, specialty, NPI number and email address. The claims administrator may fax its response back on the lower block of the form and sends decision and delay letters separately, so list the contact and fax number that actually track authorizations in the practice.
Enter the claims administrator's company name, contact name, address, phone, fax and email. Use the address, fax number or email the claims administrator designated for requests for authorization, because the receipt date that starts the review clock depends on how and when the form arrives.
For each of up to five items, enter the diagnosis (required), ICD code (required) and the specific service or good requested (required), plus the CPT or HCPCS code if known and other information such as frequency, duration and quantity. You may instead cite the page numbers of the attached report. Reference the guidelines that support the request; for treatment inconsistent with or not addressed by the MTUS, you may cite peer-reviewed, nationally recognized studies.
The signature and date line sits under the requested treatment box, and the instructions call the treating physician's signature mandatory. The parties may agree to an electronic signature. Date the form when you sign, and attach the supporting Form 5021, PR-2 or narrative before sending so the request is complete on arrival.
Leave this block blank. The claims administrator or URO may use it to record approval, denial or modification, delay, a previous denial of the same treatment, or disputed liability, with an authorization number, agent name, signature and comments, and fax it back to you. Denials, modifications and delays come with separate letters, and using this block for approvals is optional.
Download the current version from the source each time; forms change without notice.
Request for Authorization
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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A Doctor's First Report of Occupational Injury or Illness (Form DLSR 5021), a Treating Physician's Progress Report (DWC Form PR-2) or an equivalent narrative report that substantiates the requested treatment. For the request to count as complete, that documentation must have been issued or created no earlier than 30 days before submission. A request to continue therapy should also include documentation of progress.
The requested treatment table on page 1 holds up to five procedures. If you need more, list them on a separate sheet, or point to the specific page numbers of the attached medical report where the requested treatment appears. When several treatments are requested, the claims administrator notes in the comments if any single item is denied or sent to utilization review.
Only when the employee faces an imminent and serious threat to his or her health, and the request must include documentation substantiating that condition. Expedited decisions are due within 72 hours after receipt of the information reasonably necessary to decide. The rule treating faxes and emails received after 5:30 PM Pacific as next-day receipts does not apply to expedited review.
Yes, by checking the resubmission box for a change in material facts, but only when the facts behind the original utilization review decision have changed so that the decision no longer fits the employee's current condition. Include documentation of that change. Without new material facts, a denial is challenged through Independent Medical Review, which the injured worker requests.