ca-16 Authorization for Examination and/or Treatment

U.S. Department of Labor

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 OMB Cir. No.
130. Persons are not required to respond to this collection of information unless it displays a currently valid OMB 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 https://www.dol/owcp/dfec

OMB No.: 1240-0046
Expires: 01-31-2018

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. Employee's Identification (last, first, middle, SSN)

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

4. Occupation

5. Description of Injury or Disease:

6. You are authorized to provide medical care for the employee for a period of up to sixty days from the date shown in item 3, 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. SEE INSTRUCTIONS FOR
ADDITIONAL MEDICAL INFORMATION.
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.
2. There is doubt whether the employee's condition is caused by an injury sustained in the performance of duty, or is otherwise related
t o the 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 the alleged injury or to any circumstances of the employment.
Pending further advice you may provide necessary conservative treatment if you believe the condition may be to the injury or to the
employment.

7. If a Disease or Illness is Involved, OWCP Approval for Issuing
Authorization was Obtained from (Type Name and Title of OWCP
Official)

8. Name and Address of Employee’s Place of Employment
Department or Agency:
Bureau or Office:
Local Address (Including Zip Code)
9. Local Employing Agency Telephone Number (Including Area Code):

10. Name and Title of Authorized Official (Type or Print Clearly): (See
Instructions)

11. Send one copy of your report to:
U.S. DEPARTMENT OF LABOR
DFEC CENTRAL MAILROOM
P.O. BOX 8300
LONDON, KY 40742-8300

______________________________________________________________
12. I certify that I am the individual authorized by my employing agency to
13. Remarks (See Instructions under Authorized Official):
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.

____________________________________________
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-16 (Rev. xx-xx)
Previous Revision Obsolete

PART B - ATTENDING PHYSICIAN'S REPORT
14. Employee's Name (Last, first, middle)
15. What History of the Employment Injury or Disease Did The Employee Give To You?

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

16a. ICD Code(s)

No

17. What are Your Findings? (Include results of X-rays, laboratory tests, etc.)

18. What is the Diagnosed Condition(s) 18a. ICD Code(s)

19. Do You believe the Condition(s) Found was Caused or Aggravated by the Employment activity Described? (Please explain your
answer if there is doubt)
Yes

No

20. Did Injury Require Hospitalization? If yes,
date of admission (mo., day, year) Date of
discharge (mo., day, year)

Yes

21. Is Additional Hospitalization Required?

No

Yes

No

22. Surgery (If any, describe type)

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(s) of Treatment (mo., day, year)

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

30. Is Employee Able to Resume

To

31. If Employee Is Able to Resume Work, Has He/She been Advised?

Light Work

Date:

Regular Work

Date:

Yes

No

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 to a Medical
Facility, Provide Name and Address.

34. Do You Specialize?

Yes

No

(If yes, state specialty)

35. I certify that all the statements in t h i s f o r m are true and accurate to the best of my knowledge
and belief. Further, I understand that any person who knowingly makes any false statement,
misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as
provided by the FECA, including payment for medical treatment or supplies, or who knowingly
accepts compensation to which that person is not entitled is subject to civil or administrative
remedies as well as criminal prosecution and may, under appropriate criminal provisions, be
punished by a fine or imprisonment, or both, and that physicians are subject to criminal and civil
prosecution. In addition, a state or federal criminal conviction for FECA fraud will result in a
beneficiary’s termination of all current and future FECA benefits.

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

37. Tax Identification 39. Date of Report
Number
38. National Provider
System Number

______________________________________________________
Print/Typed Name/Signature of Physician (See Instructions for Definition)
PAYMENT/MEDICAL BILLING: This CA-16 guarantees payment to the original treating physician (or any physician to whom the employee was referred
by the original treating physician) for 60 days from date of issuance unless OWCP terminates this authority at an earlier date. Treatment may continue at
OWCP expense if the claim is approved. Charges for your services should be presented on the AMA standard "Health Insurance Claim Form'' (HCFA1500, OWCP-1500, OWCP-04 or the UB-04). Physician services must be itemized by Current Procedural Terminology Code (CPT) using current CPT-4
coding schema; or, the UB-04 and the coding schemas acceptable on this form.

CA-16 PAGE 2 (Rev. xx-xx)

INSTRUCTIONS FOR AUTHORIZING OFFICIAL FOR COMPLETION OF PART A. PLEASE READ FIRST. The
CA-16 is solely used by the employing agency to authorize emergency care to an injured employee. To protect
against potential fraud and abuse, it is important that this form not be duplicated or reproduced without express
written consent by OWCP to include via electronic means (including Internet postings). PLEASE ENSURE
THESE INSTRUCTIONS ACCOMPANY THE CA-16 FORM.

AUTHORIZING
OFFICIAL

SELECTION OF
PHYSICIAN

PERIOD OF
AUTHORIZATION

FEDERAL MEDICAL
FACILITIES

 Authorized personnel may include an Injury Compensation Specialist, Safety Specialist, or
Human Resources Specialist whose current position includes duties relate to the FECA
program. The injured employee’s Supervisor or other individual in their supervisory chain of
command at the time of injury may also sign and issue this form. If you are other than these
noted, please explain in the Remarks section, item 13 of the CA-16 the circumstances which
required issuance by you and to what authority, if applicable. Please be aware that union
officials, claimant representatives, or others may not serve as an authorizing official unless they
meet the criteria listed above.



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



If an employee elects to be treated by a private physician; a copy of the American Medical
Association Standard Billing Form (AMA) OWCP-1500 should be supplied together with the
submitted Form CA-16. Additionally, medical providers should register with the OWCP
Medical Bill Processing Contractor in order to receive payment. Further information can be
found on the DFEC website at https://www.dol.gov/owcp/dfec/



If an employee, in an emergency situation has to be sent and/or admitted to an Acute Care
Facility for emergency surgery or care, a copy of the OWCP Uniformed Billing Form
(UB-04-1450) should be supplied together with the submitted Form CA-16.



A physician who is excluded from the FECA program as provided at 20 CFR 10.815-826 may
not be authorized to examine or treat an injured Federal employee.



Generally, a roundtrip distance of up to 100 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. For non-emergency medical treatment, if roundtrip
travel of more than 100 miles is contemplated, or air transportation or overnight
accommodations will be needed, submit a written request to OWCP for prior authorization with
information describing the circumstances and necessity for such travel expenses.



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



U. S. Medical Facilities include Army, Navy, Air Force or the VA. Federal health service facilities
(health units) established under 5 USC 7901 are not U.S. medical facilities as used herein (see
20 CFR 10.300).



The term "injury" includes damage to or destruction of medical braces, artificial limbs and other
prosthetic devices. Eyeglasses and hearing aids are included only if the damages were
incidental to a personal injury which required medical services. Treatment for illness or disease
should not be authorized unless approval is first obtained from OWCP. Simple exposure to a
workplace hazard, such as an infectious agent, does not constitute a work place injury, entitling
an employee to medical treatment under FECA.



Qualified hospital means any hospital licensed as such under State law which has not been
excluded by the FECA program in accordance with its governing regulations. Except as
otherwise provided by regulation, a qualified hospital shall be deemed to be designated or
approved by OWCP.



Qualified provider of medical support services or supplies means any person, other than a
physician or a hospital, who provides services, drugs, supplies and appliances for which OWCP
makes payment who possesses any applicable licenses required under State law, and who has
not been excluded.

DEFINITION OF
INJURY

QUALIFIED
MEDICAL
FACILITY/
PHYSICIAN

 The term “physician” includes doctors of medicine (MDs), surgeons, podiatrists, dentists, clinical

CA-16 PAGE 3 (Rev. xx-xx)

psychologists, optometrists, chiropractors, and osteopathic practitioners within the scope of
their practice as defined by State law. The reimbursable services of chiropractors under the
FECA are limited by statute to physical examination related laboratory test and X-rays to
diagnose a subluxation of the spine and treatment consistent of manual manipulation of the
spine to correct a subluxation demonstrated by X-ray.

FORM
COMPLETION



Qualified physician means any physician who has not been excluded under the provisions of
subpart I of this part. Except as otherwise provided by regulation, a qualified physician shall
be deemed to be designated or approved by OWCP. (See 20 CFR. 10.5, WHAT
DEFINITIONS APPLY TO REGULATIONS IN THIS SUBCHAPTER)



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 B2 in Item 6, whichever is appropriate.



Send the completed form to the OWCP address shown in item 11. Send original and one copy of
Form CA-16 to the medical officer or physician. If issued for illness or disease, a copy must also
be sent to OWCP.

ADDITIONAL

INFORMATION

 See 20 CFR and/or Publication CA-810, Injury Compensation for Federal Employees.

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-16 PAGE 4 (Rev. xx-xx)

INSTRUCTIONS FOR AUTHORIZED PHYSICIAN/MEDICAL FACILITY FOR COMPLETION OF PART B

YOUR
AUTHORIZATION



Please read Part A of Form CA-16. You are authorized to examine and provide treatment for the
injury or disease described in Item 5, for a period of not more than 60 days from the date of
injury, subject to the conditions in Item 6. A physician who is debarred from the FECA program
as provided at 20 CFR 10.815-826 may not be authorized to examine or treat an injured Federal
employee. Authorization may be terminated earlier upon written notice from OWCP. For
extension of the authorization to treat beyond the 60 day period, forward your request to the
address shown in Part A. Item 11.



This form covers office visits and consultations, laboratory work, hospital services (including
inpatient), x-rays, MRIs, CT scans, physical therapy, emergency services (including surgery) and
chiropractic services. Chiropractic services are limited to charges for physical examinations and
x- rays to diagnose a subluxation of the spine and treatment consisting of manual manipulation
of the spine to correct a subluxation demonstrated by x-ray.



This form does not cover elective and non-emergency surgery, home exercise equipment,
whirlpools, mattresses, spa/gym membership and work hardening programs. ALSO,
PLEASE NOTE THIS AUTHORIZATION DOES NOT INCLUDE PRESCRIPTIONS FOR
COMPOUND MEDICATION.



You may utilize consultants, laboratories and local hospitals, if needed. A private room may be
authorized only if the diagnosed condition is medically necessary as determined by the treating
physician and concurred by the OWCP District Medical Advisor. Ancillary treatment may be
provided to a hospitalized employee as necessary.



After examination, complete items 14 through 39, of Part B, and send your report, together with
any additional narrative or explanatory material, to the address listed in Part A, item 11. If the
employee sustained a traumatic injury and is disabled for work, reports on Form CA 17, ''Duty
Status Report'' may be required by the employing agency during the first 45 days of disability.
If disability continues beyond 45 days, monthly reports should be submitted. Reports from all
consultants are also required. Delay in submitting medical reports may delay payment of
benefits.

RELEASE OF
RECORDS



Injury reports are the official records of OWCP. They shall not be released to anyone nor may
any other use be made of them without the approval of OWCP.

BILLING FOR
SERVICES



All medical providers must be enrolled with our Medical Bill Processing Contractor in order to
receive authorization and payment. Additional information can be found on our website at
www/dol.gov/owcp/dfec.



If an employee elects to be treated by a private physician, a copy of the American Medical
Association Standard Billing Form (AMA) OWCP-1500 should be supplied together with the
submitted Form CA-16.



OWCP requires that when services are provided by a private physician, charges be itemized
using the AMA standard Health Insurance Claim Form, HCFA-1500/OWCP-1500. The form
should contain appropriate International Classification of Disease (ICD) coding schemas in
Block-21, and related correctly to the Diagnosis Pointers referenced in Block 24E. The form
should also identify services rendered using the Current Procedural Terminology (CPT-4), and
HealthCare Common Procedure Codes (HCPC) schemas.



OWCP requires that when services are performed in an emergency situation, and in an Acute
Care Facility for emergency surgery or care, a copy of the OWCP Uniformed Billing Form
(UB-04-1450), should be supplied together with the submitted Form CA-16. The form should
contain the appropriate International Classification of Diseases (ICD) coding schemas in
Blocks 66-70, and reference any surgical procedures performed in the facility in Blocks 74a-74e
using the International Classification of Disease ( ICD) Surgical Procedure Codes. The UB-04
should be itemized in Block #42 in a summarization listing all ancillary services performed during
the stay, and each service; (radiology, Labs, pharmacy, supplies, etc.,) should be referenced
using Revenue Center Codes (RCC).Payment for chiropractic services is limited to charges for
physical examinations, related laboratory tests, and X-rays to diagnose a subluxation of the spine;
and treatment consisting of manual manipulation of the spine to correct a subluxation
demonstrated by X-ray.



The Provider/Facility Tax Identification Number (TIN) is an important identifier in the OWCP
system. To ensure accurate processing and to reduce inaccuracy of payment, the provider billing
on an OWCP-1500 billing form should reference the TIN (Employer Identification Number or
SSN in Block #25), and indicate this identifier on all submitted reports and billings submitted
consistently. The Tax Identification Number for Facilities billing on the UB-04 Billing form, should
reference their Federal Tax Identification number in Block #5.

USE OF CONSULTANTS

AND HOSPITALS

REPORTS

TAX IDENTIFICATION
NUMBER

CA-16 PAGE 5 (Rev. xx-xx)

ADDITIONAL
INFORMATION

REQUESTS FOR
ACCOMMODATIONS OR
AUXILIARY AIDS AND
SERVICES



Refer to Information for Medical Providers at http://www.dol.gov/owcp/dfec/



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.

PUBLIC BURDEN STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average five
minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and
completing and reviewing the collection of information. The obligation to respond to this collection is voluntary (5 U.S.C. 8101 et seq.) to
obtain or retain a benefit. Send comments regarding the burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the Office of Workers' Compensation Programs, U.S. Department of Labor, Room S3229, 200
Constitution Avenue, N.W., Washington, D.C. 20210, and reference the OMB Control Number 1240-0046. Note: Do not submit the
completed claim form to this address.

PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby 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.
Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the processing and
adjudication of the claim you filed under the FECA.

CA-16 PAGE 6 (Rev. xx-xx))