Tyrone Bentley
 
 From dcatalyst16 
 18493787525 
 8/29/2022 10:58:59 PDT 
 Page 04 of 17 
 Dr Elizabeth Mejia MD 
 Physical Medicine and Rehabilitation 
 Aug 25, 2022 
 RehabOne 
 RehabOne Programs I GROUNNING PEDICAL 
 REQUEST FOR AUTHORIZATION 
 PLEASE SEE DWC FORM RFA ATTACHED. 
 26/09/15 
 patient name: 
 Tyrone Bentley 
 EMPLOYER: 
 Healthcare Service Group 
 injury date: 
 05/08/19 
 Primary Treating Physician: Dr Elizabeth Mejia MD 
 PHYSICAL MEDICINE AND REHABILITATION NEW PATIENT EVALUATION 
 (DOCTOR'S FIRST REPORT) 
 Dear Gentlepersons: 
 I had the opportunity to evaluate Ms. Corona for a new patient evaluation today. 
 BILLING ATTESTATION: 
 Ms. Araceli Corona DOB was verified prior to disclosing any PHI. 
 16 Corona, Araceli : Aug 25, 2022 
 page 3
