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Health Care Information Request For Treatment Authorization

Written authorization must be obtained for special service(s) costing over $1,000 in a non-emergency situation or requiring pre-authorization pursuant to the Medical Treatment Guidelines (MTG). With limited exceptions, care that is provided consistent with MTG recommendations does not require pre-authorization. Pre-authorization is only required for the 11 procedures and second surgeries listed in the Medical Treatment Guidelines for the Mid and Low Back, Neck, Shoulder, Knee, Carpal Tunnel Syndrome and Non-Acute Pain.

How to Request Authorization

  1. Complete:
  2. Search for the insurance carrier's designated contact.
    • Note: Failure to submit the request to the designated contact identified on the Workers' Compensation Board website may result in your request being denied.
    • Typing the Insurer's ID (W#) or name in the search box directly above the table will help to narrow the list.
    • Search for Contacts
  3. Fax or email the form to the insurer's designated fax/email address. If you are unable to send or receive fax or email, mail the form with a return receipt requested. If the Claim Administrator (Insurer or Third-Party Administrator) asks that an alternate contact be used, identify the alternate contact on the form and send the request to both the designated and alternate contact..
  4. Send a copy to the Workers' Compensation Board, the patient's legal representative if any, or the patient if they are not represented.

It is the attending physician's burden to set forth the medical necessity of the special services required. Be sure to provide this information in the Statement of Medical Necessity section of the form.

This form should include your patient's WCB case number and the insurer's case number. It must be signed by the attending doctor and contain her/his WCB authorization number. If the patient is hospitalized, it may be signed by a licensed doctor to whom the treatment of the case has been assigned as a member of the attending staff of the hospital.

SPECIAL SERVICES - Services for which authorization must be requested are as follows:

Determining the Insurance Carrier

You can use Does Employer Have Coverage? to find the name of the employer's insurance carrier. If several insurers are listed for that employer, choose the one who provided coverage during the injured worker's date of accident.

Contact Us

Please email or call (877) 632-4996 if you have questions regarding this form.