Fillable U.S. Department of Labor (Department of Labor)

Fill Online, Printable, Fillable, Blank U.S. Department of Labor (Department of Labor) Form

Use Fill to complete blank online DEPARTMENT OF LABOR (DC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

U.S. Department of Labor (Department of Labor)

On average this form takes 14 minutes to complete

The U.S. Department of Labor (Department of Labor) form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 57 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Department of Labor

BROWSE DEPARTMENT OF LABOR (DC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
U.S. Department of Labor
Attending Physician's Report
Office of Workers' Compensation Programs
2. Date of Injury
3. OWCP File Number
Middle
OMB No. 1240-0046
Expires: 03-31-2021
First
1. Patient's name Last
4. What history of the employment injury (including disease) did the patient give to you?
6. What are your findings? (Include results of X-Rays, laboratory reports, etc.)
7. What is your specific diagnosis(es) related to the employment activity?
ICD Code(s)
8. Do you believe the condition(s) found was caused or aggravated by an employment activity as described in item 4.? (Please explain answer)
Yes
Date of admission
12. Additional Hospitalization required
If Yes, describe in "Remarks"
11. Date of discharge
Did injury require hospitalization?
If no, go to item # 13
(Item 25)
13. What treatment did you provide?
16. Date of discharge from treatment
14. Date of first examination
15. Date(s) of treatment:
mo. day yr.
work
the type of work that could reasonably be performed with these limitations. (Continue in item
#25 if necessary.)
25. Remarks
CA-20 (Rev. 08-14)
9.
20. Date employee is able to resume regular
23. If employee is able to resume only light work, indicate the extent of physical limitations and
Name
10.
26. If you have referred the employee to another physician provide the following:
Record of Examinaton
From mo. day yr. Thru mo. day yr.
mo, day yr.
mo, day yr. mo, day yr.
mo. day yr.
mo. day yr. mo. day yr. mo. day yr.
(If yes, please describe)
5. Is there any history or evidence of concurrent or pre-existing injury or disease or physical impairment?
ICD Code(s)
Yes No
No
If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or
modifications, please contact OWCP. See form instructions for Requests for Accommodations or Auxiliary Aids and Services.
NoYes
17. Period of total disability
18. Period of Partial Disability
19. Date employee able to resume
light work
From mo. day yr. Thru
mo. day yr.
mo. day yr.
mo. day yr.
21. Has employee been advised that
he/she can return to work?
Yes
No
22. If yes, on what date was he/she advised?
mo. day yr.
24. Are any permanent effects expected as a
result of this injury? If yes, describe in
item #25.
Yes
No
Specialty
ZIP
Consultation
Treatment
Address
City
State
27. What was the reason for this referral?
Signature
28. I certify that the statements in response to the questions asked above are true, complete and correct to the best of my knowledge. Further, I
understand that any false or misleading statements or any misrepresentation or concealment of material fact which is knowingly made may
subject me to criminal prosecution.
Signature of Physician
Date
29. Name of Physician
30. Tax ID Number
Address
31. Do you specialize?
No
City State ZIP
32. If yes, indicate specialty
Yes
Yes
No
Print
Reset
A medical report is required by the Office of Workers' Compensation Programs before
payment of compensation for loss of wages or permanent disability can be made to the
employee.
This information is required to obtain or retain a benefit (5 U.S.C. 8101, et seq.). If you have
submitted a narrative medical report or a form CA-16 to OWCP within the past 10 days, you
need not submit this form CA-20.
OWCP requires that medical bills, other than hospital bills, be submitted on the American
Medical Association health insurance claim form, HCFA 1500/OWCP-1500.
INSTRUCTIONS TO PHYSICIAN FOR COMPLETING ATTENDING PHYSICIAN'S REPORT
2. IF DISABILITY HAS NOT TERMINATED, INDICATE IN ITEM 17; AND
U.S. Department of Labor OWCP/DFEC
IMPORTANT:
3. SEND THE FORM AND YOUR BILL TO:
1. COMPLETE THE ENTRIES 1-32 ON THE FORM; AND
INSTRUCTIONS FOR THE INJURED WORKER/ EMPLOYING AGENCY
P.O. Box 34090
San Antonio, TX 78265
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 and complete items 1-3 on the front. 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. 10.404). 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 Association
Guides to the Evaluation of Permanent Impairment.
Notice
Requests for Accommodations or Auxiliary Aids and Services
If you have a disability, federal law gives you the right to receive help from the OWCP in the form of
communication assistance, accommodation(s) and/or modification(s) to aid you in the claims process.
For example, we will provide you with copies of documents in alternate formats, communication services
such as sign language interpretation, or other kinds of adjustments or changes to accommodate your
disability. Please contact our office or your OWCP claims examiner to ask about this assistance.
CA-20 PAGE 2 (Rev. 08-14)
Privacy Act Statement
Public Burden Statement
CA-20 PAGE 3 (Rev. 08-14)
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are here by 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
verify 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 healthcare 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.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information
unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is
estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to
respond to this collection is required to obtain or retain a benefit under 5 U.S.C. 8101, et seq. Send comments regarding
the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to
the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, NW,
Washington, DC 20210, and reference the OMB Control Number 1240-0046. Note: Please do not send the completed
form to this office.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

U.S. Department of Labor (Department of Labor)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document