Form CA-15 Peace Corps Volunteer Authorization for Examination and/

U.S. Department of Labor

Peace Corps Volunteer Authorization
for Examination And/Or Treatment

Office of Workers' Compensation Programs

The following request for information is required under (5 USC 8101 et. seq.). Benefits and/or medical services expenses may not be
paid or may be subject to suspension under this program unless this report is completed and filed as requested. Information
collected will be handled and stored in compliance with the Freedom of Information Act, the Privacy Act of 1974 and 0MB Cir. No.
130. Persons are not required to respond to this collection of information unless it displays a currently valid 0MB control number.
NOTE: THIS FORM IS NOT TO BE REPRODUCED OR DUPLICATED (See Instructions). IF INSTRUCTIONS ARE SEPARATED
FROM THIS FORM, REFER TO FORM INFORMATION htt s://www.dol/owc /dfec

0MB No.:
Expires:

PART A -AUTHORIZATION

1. Name and Address of the Medical Facility or Physician Authorized to Provide the Medical Service within the meaning of FECA (See Instructions for
definition of a qualified physician):

2. Volunteer's Identification (last, first, middle, SSN)

3. End of Service Date (Coverage Start Date)

4. Date of Injury (mo. day, yr.)

5. Description of Injury or Disease:

6. You are authorized to provide medical care for the Volunteer for a period of up to 120 days from the End of Service Date, subject to the
condition stated in item A, and to the condition indicated in either 1 or 2, item B.
A.

B.

Your signature in item 35 of Part B certifies your agreement that all fees for services shall not exceed the maximum allowable fee
established by OWCP and that payment by OWCP will be accepted as payment in full for said services. PLEASE NOTE THIS
AUTHORIZATION DOES NOT INCLUDE PRESCRIPTIONS FOR COMPOUND MEDICATIONS OR PHYSICIAN DISPENSED
MEDICATION. SEE INSTRUCTIONS FOR ADDITIONAL MEDICAL INFORMATION.

D 1. Furnish office and/or hospital treatment as medically necessary for the effects of this injury. Any surgery other than emergency must have
prior OWCP approval.

D 2. There is doubt whether the employee's Volunteer's condition is caused by an injury sustained in the performance of duty, or is otherwise

related to Peace Corps service. You are authorized to examine the Volunteer using indicated non-surgical diagnostic studies, and
promptly advise the undersigned whether you believe the condition is due to the alleged injury or to any circumstances of the volunteer
service. Pending further advice you may provide necessary conservative treatment if you believe the condition may be related to Peace
Corps service.

8. Name and Address of Peace Corps Office

9. Peace Corps Telephone Number (Including Area Code):

Department or Agency: Peace Corps
Bureau or Office: Office of Health Services
Local Address (Including Zip Code)
10. Name and Title of Authorized Official (Type or Print Clearly): (See
Instructions)

11. Send one copy of your report to:
OWCP/DFEC
P.O. Box 34090
San Antonio, Texas 78265

12. I certify that I am the individual authorized by Peace Corps to issue this
form concerning medical treatment. I further certify that the information
provided above is true and accurate to the best of my knowledge and belief.
I realize that any person who knowingly makes any false statement or
misrepresentation to obtain FECA compensation is subject to civil or
administrative remedies as well as criminal prosecution.

13. Remarks (See Instructions under Authorized Official):

Signature of Authorizing Official/Date (Month, Day/Year)

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.
CA-15 (Rev. XX-XX)

Qualified hospital

Qualified provider of medical support services or supplies

PLEASE NOTE THIS AUTHORIZATION DOES NOT INCLUDE PRESCRIPTIONS FOR
COMPOUND MEDICATION
.