Notice to Reviewer

Authorization for Examination And/Or Treatment

1240-0046

November 2018

NOTE TO REVIEWER

Justification for nonmaterial change:

The agency, in order to provide clearer guidance to respondents, seeks to make two clarifications to the Authorization for Examination And/Or Treatment, Form CA-16.

1. The first clarification applies to item 6, on page 1, which currently reads:

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.

The revised statement of item 6 would read:

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.

2. The second clarification applies to the 3^rd bullet in the Instructions on page 5, under YOUR AUTHORIZATION, which currently reads:

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.

The revised statement would read:

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, OR PHYSICIAN DISPENSED MEDICATIONS BILLED WITH HCPCS CODES J3490, J3590, J7999, J8499, J8999 OR J9999.