ca-20 Attending Physicians Report

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U.S. Department of Labor

Attending Physician's Report

Office of Workers' Compensation Programs

Record of Examinaton
1. Patient's name

2. Date of Injury
mo, day yr.*

Middle

First

Last

*

3. OWCP File Number OMB No. 1240-0046
*
Expires: XX-XX-XXXX

4. What history of injury (including disease) did patient give you?

*
5. Is there any history or evidence of concurrent or pre-existing injury or disease or physical impairment?
* (If yes, please describe)
Yes

ICD-9 Code

No

6. What are your findings? (Include results of X-Rays, laboratory reports, etc.)

*
ICD-9 Code

7. What is your diagnosis?

*

*
8. Do you believe the condition found was caused or aggravated by an employment activity? (Please explain answer)
Yes

*

No
12. Additional Hospitalization required
If Yes, describe in "Remarks"
(Item 25)
Yes
No

11. Date of discharge
mo, day yr.

10. Date of admission
mo, day yr.

9. Did injury require hospitalization?
* If no, go to item # 13 Yes
No
13. What treatment did you provide?

14. Date of first examination
mo. day yr.

*

17. Period of total disability
From
mo. day yr. Thru

15. Date(s) of treatment:
mo. day yr.

mo.

day

20. Date employee is able to resume regular
work
mo. day yr.

mo.

day

mo.

yr.

18. Period of Partial Disability
From
mo. day yr. Thru

yr.

21. Has employee been advised that
he/she can return to work?

*

Yes

mo.

day

day

yr.

yr.

16. Date of discharge from treatment
mo. day yr.
19. Date employee able to resume
mo. day yr.
light work

22. If yes, on what date was he/she advised?
mo. day yr.

No

23. 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. (Continue in item
#25 if necessary.)

24. Are any permanent effects expected as a
result of this injury? If yes, describe in
* item #25.
Yes
No

25. Remarks

26. If you have referred the employee to another physician provide the following:
Name

Specialty

Address

27. What was the reason for this referral?

City

State

Consultation

ZIP

Treatment

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
that any false or misleading statements or any misrepresentation or concealment of material fact which is knowingly made may
* understand
subject me to felony criminal prosecution.

*

Signature of Physician

Date

29. Name of Physician

30. Tax ID Number

*

*

Address

31. Do you specialize?

*
City

*
State

ZIP

Yes

No

32. If yes, indicate specialty

*
CA-20 (Rev. 05-11)

INSTRUCTIONS TO PHYSICIAN FOR COMPLETING ATTENDING PHYSICIAN'S REPORT
.

1. COMPLETE THE ENTRIES 1-32 ON THE FORM; AND
2. IF DISABILITY HAS NOT TERMINATED, INDICATE IN ITEM 17; AND
3. SEND THE FORM AND YOUR BILL TO:

OFFICE OF WORKERS' COMPENSATION PROGRAMS
DOL DFEC Central Mailroom
PO Box 8300
London, KY 40742-8300

IMPORTANT: A MEDICAL REPORT IS REOUIRED 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 FOR THE INJURED WORKER/ EMPLOYING AGENCY
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127,&(
,f you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the
right to receive help from DFEC in the form of communication assistance, accommodation and modification to aid you in
the FECA 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 account for
the limitations of your disability. Please contact our office or your claims examiner to ask about this assistance.

For Sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, DC 20402

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