ca-16 Authorization for Examination and/or Treatment

department sf Labar

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Authorization 'For Examinatiorc
And/or Treatment

Employment Standards Administration
Office of Workers' Compensation Programs
The following request for information is required under (5 USC 8101 et. seq.). Benefits andlor medical services expenses
may not be paid or may be subject to suspension under lhis program unless this report is completed and filed as requested.
information colleded wili be handled and stored in compliance with the Freedom of Information Ad, lhe Privacy A d Of 1974
and OMB Cii. No. A-108.
i formPersons are not required to respond lo this collection of n

a currently valid OMB wntr-r.

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OM6 No.: 1215-0103
Expires: 10-31-2008

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PART A AUTHORIZATION
1. Name and Address of the Medical Facility or Physician Authorized to Provide the Medical Service:

3. Dateof Injury (mo. Day, yr.)

2. Employee's Name (last, first, middle)

4. Occupation

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5. Description of injury or Disease:

6. You are aulhorized to provide medical care for lhe employee for a period of up to sixty days from the date shown in item 11, subject to h e
condition staled in item A, and to the condition indicated eilher 1 or 2, in item 8.

A.

Your signature in item 35 of Part B celtifies your agreement that all fees for services shall not exceed the maximum allowable fee established
by OWCP and that payment by OWCP wili be acoepted as payment in full for said services.

B.

[7 I.

Furnish office andlor hmpitai treatment as medically necessary for the effects of h i s injury. ~ n surgery
y
other than emergency
must have prior OWCP approval.

2. There is doubt whemer the employee's condition is caused by an injury sustained in the performanceof duty, or is otherwise
related to lhe employment. You are authorized to examine the employee using indicated non-surgical diagnostic studies, and
promptly advise the undersigned whether you believe the condition is due to lhe alleged injury or to any drwmstances of lhe
employment. Pending further advice you may provide necessary mnservative treatment if you believe the condition may be to
lhe injury or to the employment.
7. if a Disease or illness is involved. OWCP Approval for issuing
Aumorization was obtained from: (Type Name and Title of OWCP
Official)

8. Signature of Aulhorizing Official:

9. Name and Title of Authorizing Official: (Type or print dearly)

U.S. DEPARTMENT OF
. LABOR
--Employment Standards Mminlstration
Otfiu) of Worken' Compensatoon Propruns

Department of Agency

Bureau or ORice

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Local Address (including ZIP Code)

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Public Burden Statement
We estimate that it will take an average of 5 minutes to m p i e t e this milection of information, including time for reviewing instructions,searching
existing daia soures, yathering and maintaining :he dais needed, and compieiing and reviewing the colleciion of information. if you have any
m l n e n t s regarding these siimales or any othsi aspeci of this colieclion of irr:olmaiion. including suggestions for reducing mis burden, send them
LO the Gifin I;V!lcriiew' Cornpensation Piwrams. V.S. Deparbnenl nl Labor, k o r , l 5-3229, 200 Consliiuiion Avenue, i\l.W.. Washingion. D.C.
lTJ'710.

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14. Employee's Name (last, iirsi, r!-#iddie)

15. What History of Injury or Disease Did Employee Give You?

16. Is there any History or Evidence of Concurrent or Pre-existing Injury, Disease, or Physical Impairment?
(If yes, please describe)

17

Yes
NO
17. What are Your Findings? (Indude results of X-rays, laboratory tests, etc.)

18. What is Your Diagnosis?

16a. i D G 9 Code

L

L

L

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18a. IDC-9 Code

i
i
u
19. Do You Believe lhe Condition Found was Caused or Aggravated by the Employmenl Activity Described? (Please explain your answer if there is
doubt).

17 yes

17 No

20. Did injury Require Hospitalization?

n

yes

U No

21. ISAdditional Hospitalization Required?

If yes, date of admission (mo.. day, year)

• Yes

Date of discharge (mo.. day, year)
22. Surgery (If any, describe type)

NO

23. Date Surgery Performed (mo.. day, year)

24. What (Other) Type of Treatment Did You Provide?

25. What Permanent Effects. If Any. Do You
Anticipate?

26. Date of First Examination (mo.. day, year)

28. Date of Discharge from Treatment (mo., day, year)

27. Date@)of Treatment (mo.. day. year)

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29. Period of Disability (mo., day, year)(lf termination date unknown, so
indicate)
Total Disability: From
To
TO
Partial Disability: From

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30. Is Employee Able to Resume

17 Light Work

Dale:
Date:

n Remarwork

31. If Employee is Able to Resume Work. Has HelShe Been Advised?

If Yes, Furnish Date Advised

32. If Employee is Able to Resume Only Light Work, Indicate the Extent of Physical Limitations and the Type of Work that Could Reasonably be
Performed with these Limitations.

33. General Remarks and Recommendations for Future Care, if Indicated. If you have made a Referral to Another Physician or lo a Medical Facility.
Provide Name and Address.

34. Do You Specialize?

0 Yes

U No

(If yes, state specially)

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35. SIGNATURE OF PHYSICIAN. i cer3ty that all the statements in
response to the questions asked in Part B of this form are true.
complete and correct to the best of my knowledge. Further, I
understand that any false or misleading slatement or
misrepresentation or concealment of material fact which is knowingly
made may subject me to felony criminal prosecuson.

36. Address (No.. Street, City. State. ZIP Code)

37. Tax

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38. National Provider System Number

MEDICAL BILL: Charges for your services should be presented to the AMA standard "Health Insurance Claim From'' (AMA OP 40714081409; OWCP1500a. or HCFA 1500). Service must be itemized by Current Procedural Teminoloyy Code (CPT 4) and the form must be signed.

For sale by the Superintendent of Documents. U.S. Governnlent Prinliny Office. Washington. DC 20402

SELECTION OF
PHYSICIAN

O

A Federal employee injured by accident while in the performance of duty has the initial right to
select a physician of hislher choice to provide necessary treatment. The supervisor shall
immediately authorize examination and appropriate medical care by use of Form CA-16 to either a
United States medical officerlhospitai or any duly qualified physicianlhospital of the employee's
choice.

If the employee elects to be treated by a private physician, a copy of the American Medicai
Association standards billing form (AMA OP 40714081409: OWCP-1500a) should be supplied
together with Form CA-16.

A physician who is debarred fmm the FECA program as provided at 20 CFR 10.450-457 may not
be authorized to examine or treat an injured Federal employee.

Generally. 25 miles from the place of injury, employing agency, or the employee's home is a
reasonable distance to travel for medical care; however, other pertinent factors must also be
considered.

PERIOD OF
AUTHORIZATION

0

Form CA-16 is valid for up to sixty days from date of issuance, and may be terminated earlier upon
written notice from OWCP to the pmvider. It should not be used to authorize a change of
physicians after h e initial choice is exercised by the employee.

FEDERAL MEDICAL
FACILITIES

0

U.S. medical facilities include Public Health Service, Military or VA hospilals. Federal health
service facilities (health units) established under 5 USC 7901 are not U.S. medical facilities as
used herein (see 20 CFR 10.400).

DEFINITION
OF INJURY

0

The term "iniurV includes damage to or destruction of medical braces, artificial limbs and omer
prostnet c de-v &s Eyeglasses a-nd hear ng aios are included 0n.y if tne oamages were inciaental
to a personal in.ury whtch req~lredmeo cal sewces. Treatment for. mess or dlsease shoula not
oe a~thonzedunless approva. 1s first oblalned horn OWCP

DEFINITION OF
PHYSICIAN

0

The term 'physician" includes doctors of medicine (MD), surgeons, podiabists, dentists, clinical
psychologists, optometrists, chiropractors and osteopathic practitioners within h e swpe of their
practice as defined by Slate law. The reimbursable services of chimpractors under the FECA are
limited bv SlatUte to Dhvsical examination. related laboratorv tests and X-ravs to diagnose a
subiuxati&n of the spine; and treabnent coniisting of manual manipulation of therpine to correct a
subluxation demonstrated by X-ray.

FORM
COMPLETION

0

Part A shall be completed in full by the authorizing official. The authorization is not valid unless
the name and address of the physician or hospital is entered in Item 1 and the signature of the
authorizing official appears in Item B. Check B1 or 8 2 or Item 6, whichever is appropriate. In case
of illness or disease, only Box 82 may be checked.

Snow tne address of the proper OWCP Wfce in Item 12 Send or.glnal and one copy of Form CA16 10 the meo'cal officer or pnyscian. If i s s ~ e dfor thness or otsease, a copy mdst also be sent to
OWCP.

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See 20 CFR andlor Chapter 810. Federal Personnel Manual (FPM)

YOUR
AUTHORIZATION

6

Piease read Part A o i Fomi CA-16. You are authorized to examine and provide treatment for the
injury or disease described in ltem 5, for a period of not more than 60 days from the date of
issuance, subject to the conditions in ltem 6. A physician who is debal~edfrom the FECA prwram
as orovided at 20 CFR
10.450-457 mav not be authorized to examine or treat an iniured Federal
employee. Authorization may be terminated earlier upon Milien notice from OWCP. For
extension of the authorization to treat beyond the 60 day period, apply to the omce shown in Part
A. Item 12.
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This form coven ofice visits and consultations. laboratory work, hospital services (including
inpatent), x-rays. MRls. CT scans physical therapy, emergency services (.ndud'ng surgery) a n i
chiropractic serv#ces. Chiropractic serv~cesare ,m ted to cnarges b r physical examinat~onsand xr a p to d.agnose a subluxation of the spine an0 treatment consisting of manual manipulation of trle
spine to correct a subluxation demonstrated by x-ray
This form does not cover elective and non-emergency surgery, home exercise equipment.
whirlpools, mattresses, spalgym membership and work hardening programs.

USE OF CONSULTANTS
AND HOSPITALS

0

YOUmay utilize consultants, laboratories and local hospitals, if needed. Authorize semi-private
accommodations unless a private room is medically necessary. Ancillary bgabnent may be
provided to a hospitalizedemployee as necessary.

REPORTS

0

Aner examination, complete ilems 14 through 39, of Part 5,and send your report. logether with
any additional narrative or explanatory material, lo me address listed in Part A, item 12. If the
emDiovee sustained a traumatic iniurv and is disabled for work. reDorts on Form CA 17. 'Dutv
~61u;~eporl. may be require0 by'm; employ~ngagency durong me first45 days of dsabiiity i f
osability continues beyond 45 days, mon1h.y repons sh0u.d be subm~tlea. Repms hom all
consu.tants are also requlred. Delay ~nsubmlmng medical repons may delay payment of benefits

RELEASE OF
RECORDS

0

Injury rep& are the official recoms of OWCP. They shall no1 be released to anyone nor may any
other w e be made of them w.Ihou1 the approval of OWCP.

BILLING FOR
SERVICES

0

OWCP requires that charges be itemized using the AMA standard "Health insurance Claim Form"
fAMA OP 407/4081409: OWCP-1500. or HCFA-1500). Each omcedure must be identified. in
Column 24 C of me brm, by Ihe applicable ~urrent'~rocedural
Terminology (4' edltlon) Code
CPT 41 A copy of the form may be supp.~eaby the employee at the tame treatment 1s sought

0

Payment for chiropracUc services is limited to charges for physical examinations, related
laboratory tests, and X-rays to diagnose a subluxation of the spine: and treabnent consisting of
manual manipulation of h e spine to correct a subiuxation demonstrated by X-ray.

TAX IDENTIFICATION
NUMBER

0

The provider's Tax identification Number (TIN) is an important identified in the OWCP system. To
speed processing and to reducs inaccuracy of payment, the providefs TIN (Employer
Identification Number or SSN) should be shown on ail reports and billings submitted to OWCP. If
possible, providers should decide on a single TIN -either corporate or personal -which is used
consistently on OWCP claims.

ADDITIONAL
INFORMATION

0

Contact the OWCP shown in item 12 of Part A

Please Ewnovo These Unsirudions Before Submitting \'our Report.

"hOTE Tne Iol~ow~ng
statement is mane in accoroance w th the Pr vacy Act of 1974 (5 USC 552a) an0 tne Paperwork Reo~cllon
A n of 1995, as amendeo The aLlnorlly for reqLest ng lne fo ow ng informal on s Sect on 8101 e l seq Tit e 5 of the ,
S Code
authorizes collection of this information. Completion of this lorn is required in order to receive payment for medical services and
expenses associated with the iniurv or disease described in Item 5 of Ulis form for a period not more than 60 davs from the date of
Issuance s-oject to tne con0 tlon in Item 6 of tnls form Ado t onat a sclos~resof tnls inlormaton may w l o tn~rbparies n llbgal on.
emp oy ng agenc es, vano-s no v o-als and organ zallons provlo ng related medlca renao I tat,on and olher services. ns-rance
plans which may have paid related bills; labor unions: various law enforcemenl officials; other federal, state and local agencies
(including the GAO and IRS) as appropriate; data processing contracton to the Department of Labor; debt collection agendes and
credit bureaus."

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