FECA Medical Report Forms, Claim for Compensation

U.S. DEPARTMENT OF LABOR

EMPLOYMENT STANDARDS ADMINISTRATION

OFFICE OF WORKERS' COMP PROGRAMS

PO BOX 8300 DISTRICT XX

LONDON, KY 40742-8300

Phone: (XXX) XXX-XXXX

DATE

Date of Injury:

Employee:

Dear Sir/Madam:

1. The date of maximum improvement. If maximum improvement has not been reached, please state when it may be expected and your recommendations for further medical management, including the requirement for corrective lenses.

2. Current status of the injured eye. Indicate measurable defects to uncorrected vision, including central visual acuity, far and near; visual field constriction; ocular motility loss; and ability to fuse vision without glasses.

3. Present status of the uninjured eye (see above), including sympathetic involvement if present.

4. Any pathological condition observed in either eye.

5. Your recommendation of the percentage impairment of uncorrected vision on the basis of your clinical findings and the AMA Guides to the Evaluation of Permanent Impairment (Fifth Edition).

If the injury has resulted in enucleation, the examination should include a careful study of the socket of the enucleated eye. Please indicate whether any disfigurement has resulted from the enucleation and give your recommendations as to the need for a prosthesis, plastic surgery, or other treatment.

This information will be used to determine entitlement to benefits under the Federal Employees' Compensation Act.

If you find it necessary to obtain a consultation with another specialist or to hospitalize the claimant in order to render a fully rationalized opinion, please contact this office at to obtain further authorization.

To ensure timely payment, use the enclosed numbered billing Form OWCP-1500a and use the authorization number in corresponding with or calling the office about your bill. The billing form must contain the provider's signature in Block 25 and the tax identification number (Social Security Number or EIN) in Block 33. The medical report must accompany the bill to ensure prompt payment. Any bill submitted without a medical report will be held for its arrival, or returned. Payment will be made approximately 30 days from receipt of these documents.

If the marked form is damaged and cannot be used, or if two forms are required, be sure to submit the bill on a standard American Medical Association Health Insurance Claim Form (OWCP 1500a/HCFA 1500) with your authorization number clearly marked in the upper right corner.

Sincerely,

Enclosure(s): LS-205, OWCP-1500a

OMB No. 1215-0103 Expires: 08-31-2005

NOTICE TO RECIPIENT

The information requested is required for the claimant to obtain or retain a benefit under 5 U.S.C. 8101 et seq. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

We estimate that it takes an average of 20 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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.

DO NOT SEND THE INFORMATION REQUESTED TO THE ADDRESS SHOWN JUST ABOVE. RATHER, SEND IT TO THE ADDRESS SHOWN ON THE LETTERHEAD.

PRIVACY ACT

"NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following information is Section 8101, et seq., Title 5 of the U.S. Code authorizes collection of this information. Completion of this form is required for the claimant to obtain or retain a benefit Under 5 U.S.C. 8101 Et seq. The information will be used in cases involving eye injury to determine the extent of loss of vision in complicated eye injury cases. Additional disclosures of this information may be to: third parties in litigation; employing agencies, various individuals and organizations providing related medical rehabilitation and other services; insurance plans which may have paid related bills; labor unions; various law enforcement officials; other federal, state and local agencies (including the GAO and IRS) as appropriate; data processing contractors to the Department of Labor; debt collection agencies and credit bureaus.”