Tip for UR/PA (state/insurer specific)

Emergency treatment should never be delayed for authorization — seek treatment first, authorize later

Tip for UR/PA (state/insurer specific)

If treatment is denied, ask your doctor to request a peer-to-peer review with the carrier's medical reviewer

Tip for UR/PA (state/insurer specific)

Most states have an Independent Medical Review (IMR) process for treatment disputes

Workers' CompensationhardDoctor signature required

Workers' Comp Treatment Authorization Request

UR/PA (state/insurer specific) · Workers' Comp Insurers / UR Organizations

Request for approval of specific medical treatment, surgery, or diagnostic test related to a workplace injury. Insurer must respond within state-mandated timeframes.

Form Details

Total fields: 55
Auto-fillable: 30 (55%)
Time without BeneFill: 40 minutes
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Time saved: 28 minutes
Filled by: doctor
Frequency: as needed
State-specific: Yes — form may vary by state

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Where to Submit This Form

📠

Fax to the workers' comp insurance carrier's utilization review department

Your treating physician typically submits this. The fax number is on your workers' comp claim documents.

🌐

Through the carrier's provider portal (physician submits)

📬

Mail to the insurance carrier's utilization review department

Filing Deadline

Submit prior to treatment when possible. Emergency treatment does not require prior authorization.

Required Attachments

📎 Treating physician's request with diagnosis, proposed treatment, and medical justification
📎 Relevant medical records, imaging, and test results
📎 Documentation of prior treatments attempted

Processing Time

Non-urgent requests: typically 5-14 days (varies by state). Urgent/concurrent review: 24-72 hours.

What Happens Next

The utilization review organization will approve, modify, or deny the request. If denied, you can appeal through your state's workers' comp system.

Tips for This Form

✓ Emergency treatment should never be delayed for authorization — seek treatment first, authorize later
✓ If treatment is denied, ask your doctor to request a peer-to-peer review with the carrier's medical reviewer
✓ Most states have an Independent Medical Review (IMR) process for treatment disputes
✓ Keep records of all treatment authorization requests and responses

More Workers' Compensation Forms

First Report of Injury (Generic FROI)

FROI · State Workers' Compensation Agencies

Report of workplace injury or occupational disease filed with the state agency and insurer. Required within 3-10 days of injury depending on state. Establishes the claim in the system.

California Workers' Comp Claim Form

DWC-1 · California Division of Workers' Compensation

Employee claim form for workers' compensation benefits in California. Employer must provide within one working day of learning of a workplace injury or illness.

New York Employee Claim

C-3 · New York Workers' Compensation Board

Employee's claim for compensation filed with the NY Workers' Compensation Board. Must be filed within 2 years of the accident or within 2 years of when the claimant knew or should have known the condition was work-related.

Texas Employee's Claim for Compensation

DWC-041 · Texas Department of Insurance, Division of Workers' Compensation

Employee's claim for compensation for a work-related injury or illness in Texas. Must be filed within one year of injury or within one year of when the employee knew or should have known the condition was work-related.

Florida First Report of Injury or Illness

DFS-F2 · Florida Division of Workers' Compensation

Florida's first report of injury or illness form. Employer must file within 7 days of knowledge of an injury or within 24 hours if the injury results in death.

North Carolina Notice of Accident to Employer

Form 18 · North Carolina Industrial Commission

Notice of Accident to Employer and Claim of Employee. Must be filed when injured on the job in North Carolina. Written notice to employer required within 30 days; claim filed within 2 years.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Workers' Comp Insurers / UR Organizations or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.