[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-280963-105":53,"doc-detail-280963-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","sample-medical-authorization-memorandum","Sample Medical Authorization Memorandum","","Sample medical authorization memorandum providing instructions for Return-to-Work Coordinators regarding Workers’ Compensation medical treatment approval. The memo explains required timing after receipt of a Workers’ Compensation Claim Form, states that later authorizations come from the State Compensation Insurance Fund, and clarifies customization on departmental letterhead. It authorizes the first physician visit for an alleged work-related injury, outlines $10,000 maximum treatment limitation and statutory controls, references Labor Code provisions, and notes the California Medical Provider Network selection requirement.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/sample-medical-authorization-memorandum/280963/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/sample-medical-authorization-memorandum/280963.png","ImageObject",442,249,{"name":88,"@type":89},"Ezra","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What does the memorandum instruct Return-to-Work Coordinators to do?","Question",{"text":109,"@type":110},"Coordinators are instructed to authorize the first doctor visit for a work-related injury when notified, and to use departmental letterhead to customize the sample authorization letter if desired.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Where does subsequent medical authorization come from after the initial approval?",{"text":114,"@type":110},"Subsequent medical authorization comes directly from the State Compensation Insurance Fund after the initial process.",{"name":116,"@type":107,"acceptedAnswer":117},"What treatment limitation and guideline requirements are stated in the authorization letter?",{"text":118,"@type":110},"The authorization states a maximum limitation totaling $10,000 and requires treatment to follow the medical treatment utilization schedule under Labor Code 5307.27 or the applicable occupational medicine practice guidelines.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},280963,1790013325,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},1099514068035,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","MEMORANDUM  \nDATE: January 30, 2007  \nTO: Return-to-Work Coordinators  \nFROM: Tracy Caldwell  \nWorkers' Compensation Analyst  \nBenefits Division  \n(916) 445-9760 (916) 324-3213 fax  \nSUBJECT: Sample Medical Authorization  \nAs you know, agencies are required to authorize medical treatment within one day of receiving a Workers’Compensation Claim Form (DWC 1, SCIF 3301) . Subsequent medical authorization will come directly from State Compensation Insurance Fund.  \nAttached please find a sample medical authorization letter that you can put on your department letterhead and customize to authorize the first doctor visit when notified of a work related injury.  \nThis is not an official form and you are not required to use this letter, or any other letter. You are only required to authorize treatment and that authorization can be done in any manner you choose (phone call, fax, memo, etc) .  \nIf you have any questions, please contact Tracy Caldwell at [tracycaldwell@calhr.ca.gov](tracycaldwell@calhr.ca.gov)  \n1515 \"S\" Street, North Building, Suite 400, Sacramento, CA 95814-7243  \n[www.dpa.ca.gov](www.dpa.ca.gov)  \nReturn-to-Work Coordinators January 30, 2007  \nPage 2  \nDate  \nPhysician Name Address  \nCity, State, ZIP  \nEmployee Name:  \nDate of Injury:  \nType of Injury Reported:  \nDear Doctor  \nThe above employee has submitted an employee claim form, DWC-1 received on (date) . As required and limited by Labor Code 5402, this letter provides authorization of medical treatment for the alleged injury until their claim is accepted or rejected by our adjusting agency, State Compensation Insurance Fund; subject to all statutory limitations. If necessary, you will be notified when a liability decision is determined.  \nCurrently there is a maximum limitation on treatment under this authorization totaling $10,000 . All treatment provided shall be in accordance with the medical treatment utilization schedule established pursuant to Labor Code 5307.27 or the American College of Occupational Medicine’s Occupational Medicine Practice Guidelines as appropriate. All requests for treatment authorization need to be made to State Compensation Insurance Fund.  \nPlease be advised that the State of California has established a Medical Provider Network and requires our employees to select physicians within the Network, unless they have predesignated their personal treating physician with our agency.  \nThis authorization for treatment is provided under Labor Code Section 5402; and does not give rise to a presumption of liability on the part of the employing agency.  \nYou are 1) the employee’s pre-designated treating physician, 2) the employer’s designated primary care facility, or 3) the physician our employee selected from our Medical Provider Network.  \nRETURN TO WORK COORDINATOR OR DESIGNATED INDIVIDUAL FROM THE AGENCY SHOULD SIGN (with their title) AND PROVIDE THEIR PHONE NUMBER FOR CONTACT.  \ncc: State Compensation Insurance Fund Applicant Attorney if known","cbCaikKqtYLlGFdl","https://ap.wps.com/l/cbCaikKqtYLlGFdl","pdf",142402,"English","# Memorandum Instructions\n## Authorization Timing and Source\n## Customization and Non-Official Status\n## Contact Information\n# Sample Authorization Letter\n## Authorization Purpose and Scope\n## Treatment Limit and Utilization Guidelines\n## Medical Provider Network Requirement\n## Liability and Physician Selection","[{\"question\":\"What does the memorandum instruct Return-to-Work Coordinators to do?\",\"answer\":\"Coordinators are instructed to authorize the first doctor visit for a work-related injury when notified, and to use departmental letterhead to customize the sample authorization letter if desired.\"},{\"question\":\"Where does subsequent medical authorization come from after the initial approval?\",\"answer\":\"Subsequent medical authorization comes directly from the State Compensation Insurance Fund after the initial process.\"},{\"question\":\"What treatment limitation and guideline requirements are stated in the authorization letter?\",\"answer\":\"The authorization states a maximum limitation totaling $10,000 and requires treatment to follow the medical treatment utilization schedule under Labor Code 5307.27 or the applicable occupational medicine practice guidelines.\"}]","Sample Medical Authorization Memorandum | PDF",1789563268]