FORM CA-20, PHYSICIAN'S REPORT
Compensation for wage loss cannot be paid unless medical evidence has been submitted supporting disability for work
during the period claimed. For claims based on traumatic injury and reported on Form CA-1, the employee should detach
Form CA-20, complete items 1-3 on the front, and print the OWCP district office address on the reverse. The form should
be promptly referred to the attending physician for early completion. If the claim is for occupational disease, filed on Form
CA-2, a medical report as described in the instructions accompanying that form is required in most cases. The employee
should bring these requirements to the physician's attention. It may be necessary for the physician to provide a narrative
medical report in place of or in addition to Form CA-20 to adequately explain and support the relationship of the disability
to the employment.
For payment of a schedule award, the claimant must have a permanent loss or loss of function of one of the members of
the body or organs enumerated in the regulations (20 C.F.R. 10.304). The attending physician must affirm that maximum
medical improvement of the condition has been reached and should describe the functional loss and the resulting
impairment in accordance with the American Medical Association Guides to the Evaluation of Permanent Impairment.
PRIVACY ACT
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees'
Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation
Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families.
(2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may
be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed
the claimant at the time of injury in order to verity statements made, answer questions concerning the status of the claim, verify billing, and
to consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies,
other government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and
services. (5) Information may be disclosed to physicians and other health care providers for use in providing treatment or
medical/vocational rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the
claim. (6) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a
decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being
made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or
the Debt Collection Act. (7) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is
mandatory. The SSN and/or TIN, and other information maintained by the Office, may be used for identification, to support debt collection
efforts carried on by the Federal government, and for other purposes required or authorized by law. (8) Failure to disclose all requested
information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of
benefits.
Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the
processing and adjudication of the claim filed under the FECA.
