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pdfFile Number:
attendant-O-AU
OMB No: 1240-0046
Expiration Date: 3-31-2021
U.S. DEPARTMENT OF LABOR
Office of Workers’ Compensation Programs
Division of Federal Employees’, Longshore and Harbor Workers’ Compensation
Federal Employees’ Compensation Act
(OWCP/DFELHWC-FECA)
PO Box 8311
London, KY 40742-8311
Phone: 202-513-6860
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Date:
Date of Injury:
Employee:
Dear Sir/Madam:
This Office is in receipt of a request for the services of an attendant. For the purpose of making a
decision as to whether payment for services of an attendant can be authorized, additional information
is needed from you as well as your treating physician. Along with this letter, you will find two
enclosures. The first is a list of questions to which you are asked to respond. The second is a
questionnaire for completion by your physician.
Except for cases where an attendant’s allowance has been paid on an ongoing basis to the claimant
since prior to January 4, 1999, payments are to be billed by and paid directly to the professional
providing attendant services. Such services are to be rendered by a home health aide, licensed
practical nurse or similarly trained individual.
Please be advised that 20 CFR 10.314 allows payment for services of an attendant where medical
documentation supports that you require assistance to care for basic personal care needs. OWCP
will pay for attendant services as a medical service under 5 U.S.C. 8103 and such payments will be
subject to the medical fee schedule and may be reviewed to verify that necessary services are being
provided by a home health aide, licensed practical nurse or similarly trained individual.
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.
CA-1090 (Rev.03-18)
File Number:
attendant-O-AU
OMB No: 1240-0046
Expiration Date: 3-31-2021
The Federal Employees' Compensation Act allows no provision for payment of tasks
such as cooking, laundry, housekeeping, shopping, or yard work.
Sincerely,
Division of Federal Employees' Compensation
CA-1090 PAGE 2 (Rev.03-18)
File Number:
attendant-O-AU
OMB No: 1240-0046
Expiration Date: 3-31-2021
Employee:
Case Number:
Please respond to the following questions.
1. State why you believe you require the services of an attendant. Identify the specific
activities with which you require assistance. How does your condition render you
incapable of performing these activities on your own?
2. Give the approximate amount of time you believe an attendant will be required.
(State your answer in number of hours per day and number of days per week.)
3. If you wish to have a specific individual provide attendant services, state the name
and address of that person. Indicate what qualifies that person to be an attendant and
cite any credentials that person has. If that person is a family member, state his/her
relationship to you.
4. ONLY COMPLETE THIS QUESTION IF YOU HAVE BEEN IN CONTINUOUS
RECEIPT OF ATTENDANT SERVICES SINCE PRIOR TO JANUARY 4, 1999. Are you
currently in receipt of attendant services? _______If so, state how long you have had
attendant services.________ Indicate how much your attendant is paid per month.
_____If not paid in cash or if only partially paid in cash, indicate what the reasonable
monthly value of the services rendered by your attendant is? ____________
I hereby certify that the information given by me and in connection with this
questionnaire is true and correct to the best of my knowledge and belief.
Signed __________________________________________ Date ________________
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 or who
knowingly accepts compensation to which that person is not entitled is subject to
criminal prosecution or civil fraud action, and may, under appropriate criminal provisions,
be punished by fine or imprisonment, or both.
.
CA-1090 PAGE 3 (Rev.03-18)
File Number:
attendant-O-AU
OMB No: 1240-0046
Expiration Date: 3-31-2021
Employee:
Case Number:
Note to treating physician: Additional information is needed to determine whether the
disability of the federal employee you are treating warrants the services of an attendant.
Please complete the enclosed questionnaire and return it promptly to this Office. If you
need more space, use a separate sheet of paper and number your answers to
correspond with the questions.
1. When did you most recently examine the employee named above? ______________
What were the findings upon examination? ___________________________________
______________________________________________________________________
2. Explain why you believe the employee's condition warrants the services of an
attendant.______________________________________________________________
______________________________________________________________________
3. How long do you believe the employee will require the services of an attendant?
______________________________________________________________________
______________________________________________________________________
4. Is the employee living at home?
Yes or No. (Please circle)
5. Is the employee living in a residential facility? Yes or No. (Please circle). If yes, give
the name and address and phone number of that
facility.:_________________________________________
______________________________________________________________________
______________________________________________________________________
6. If the employee now has the services of an attendant, what is the name and
relationship of the attendant to the employee (if related)?
__________________________________________
7. Is the employee able to: (Check one box after each item)
Unassisted
Assisted
Not at All
(a) Travel?
(
)
(
)
(
)
(b) Walk?
(
)
(
)
(
)
(c) Feed himself/herself?
(
)
(
)
(
)
(d) Dress himself/herself?
(
)
(
)
(
)
(e) Bathe himself/herself?
(
)
(
)
(
)
CA-1090 PAGE 4 (Rev.03-18)
File Number:
attendant-O-AU
OMB No: 1240-0046
Expiration Date: 3-31-2021
Unassisted
Assisted
Not at All
(f) Use the bathroom
(
)
(
)
(
)
(g) Change
Incontinence products
(
)
(
)
(
)
(h) Get out of bed? (If so, state number
of hours per day___________)
(
)
(
)
(
)
(i) Get out of doors? (If so, state to
what extent :_________________)
(
)
(
)
(
)
(j) Take exercise? (If so, state to
what extent :_________________)
(
)
(
)
(
)
If the answer to any of the above items is 'Not at All', please give detailed reasons.
______________________________________________________________________
______________________________________________________________________
7. If the employee now has the services of an attendant, identify the actual duties
performed by the attendant:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
8. Outline all other facts with reference to the employee's behavior or activity which are
pertinent to the need for an attendant:
______________________________________________________________________
______________________________________________________________________
9. I certify that all statements in response to the questions asked on this form are true,
complete and correct to the best of my knowledge. I further understand that any
knowingly false statement, misrepresentation or concealment of fact may subject me to
criminal or civil prosecution.
(Signature) _________________________________ (Date) ______________________
Name__________________________ Physician Specialty ______________________
CA-1090 PAGE 5 (Rev.03-18)
File Number:
attendant-O-AU
OMB No: 1240-0046
Expiration Date: 3-31-2021
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond
to this collection of information unless it displays a currently valid OMB control number.
Public reporting burden for this collection of information is estimated to average 10
minutes per response, including time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. The obligation to respond to this collection is required to obtain
or retain a benefit under 5 U.S.C. 8101, et seq. 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, and
reference the OMB Control Number 1240-0046. Note: Please do not return the
requested information to the address shown just above. Rather, send it to the address
shown on the letterhead.
Privacy Act Statement
The Privacy Act of 1974 as amended (5 U. S.C. 552a) and the Federal Employees’
Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.), authorizes
collection of this information. The purpose of this form is to determine authorization and
payment for services of an attendant where it is medically documented that an injured
worker requires assistance to care for personal needs such as bathing, dressing, eating,
etc. Completion of this form is voluntary (5 U.S.C. 8101, et seq.), however, failure to
provide the information may result in the delay of processing of the claim or payment or
benefits, or may result in an unfavorable decision or reduced levels of benefits.
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.”
CA-1090 PAGE 6 (Rev.03-18)
| File Type | application/pdf |
| File Title | Microsoft Word - Letters4 |
| Author | dbonacco |
| File Modified | 2020-09-30 |
| File Created | 2020-08-06 |