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).

0MB No.: 1240-0059
Expires: 04/30/2023

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.

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 OR OPIOID MEDICATIONS OR PHYSICIAN DISPENSED MEDICATION. SEE
INSTRUCTIONS FOR ADDITIONAL MEDICAL INFORMATION.

B.

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

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:
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

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-XXXX)

PART B - ATTENDING PHYSICIAN'S REPORT

14. Peace Corps Volunteer's Name (Last, first, middle)
15. What History of the Injury or Disease Did the Volunteer Give To You?

16. Is there any History or Evidence of Concurrent or Pre-existing Injury, Disease, or Physical Impairment? (If
yes, please describe)
0Yes
No

16a. ICD Code(s)

D

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 Peace Corps Service activity Described? (Please explain your
answer if there is doubt)
0

0No
0 Yes

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

I 21. Is Additional Hospitalization Required?

D Yes

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)

I 27. Date(s) of Treatment (mo., day, year)
I

I

29. Period of Disability (mo., day, year) (If termination date unknown, so
indicate)
To
Total Disability: From
Partial Disability: From
To
31. If Volunteer Is Able to Resume Work, Has He/She been Advised?

-

□
□

D

Yes

-

If Yes, Furnish Date Advised

32. Are there any Limitations on the Volunteer's Work Abilities? lf so, 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?

0 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 Provide
System Number

PAYMENT/MEDICAL BILLING: This CA-15 guarantees payment to the original treating physician (or any physician to whom the employee was
referred by the original treating physician) for 120 days from the End of Service Date 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" (HCFA-1500, 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-15 PAGE 2 (Rev. XX-XXXX)

INSTRUCTIONS FOR AUTHORIZING OFFICIAL FOR COMPLETION OF PART A. PLEASE READ FIRST. The
CA-15 is solely used by the Peace Corps to authorize initial care to an injured Volunteer. 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-15 FORM.

AUTHORIZING
OFFICIAL

•

SELECTION OF
PHYSICIAN

•
A Peace Corps volunteer injured while in the performance of duty has the initial right to select a
physician of his/her choice to provide necessary treatment.

PERIOD OF
AUTHORIZATION

FEDERAL MEDICAL
FACILITIES

includes duties related to the FECA program.

•

If a Volunteer 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-15. 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 a Volunteer 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-15.

•

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,including Peace Corps Volunteers.

•

Generally, a roundtrip distance of up to 100 miles from the place of injury, employing agency, or
the Volunteer'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-15 is valid for up to 120 days from the End of Service date, 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
Volunteer.

•

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. 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

DEFINITION OF
INJURY

QUALIFIED
MEDICAL
FACILITY/
PHYSICIAN

Authorized personnel may include any Office of Health Services staff whose current position

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.
•

The term "physician" includes doctors of medicine (MDs), surgeons, podiatrists, dentists, clinical

CA-15
CA-15 PAGE
PAGE 3
3 (Rev.
(Rev. XX-XXXX)
XX-XX)

FORM
COMPLETION

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.
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 SU8CHAPTER)
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 8. Check 81 or 82 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-15 to the medical officer or physician. If issued for illness or disease, a copy must
also be sent to OWCP.

•

See 20 CFR

ADDITIONAL

INFORMATION

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-15 PAGE 4 (Rev. XX-XXXX)

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

YOUR
AUTHORIZATION

•

Please read Part A of Form CA-15. You are authorized to examine and provide treatment for the
injury or disease described in Item 5, for a period of not more than 120 days from the End of
Service date, 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, including Peace Corps Volunteers. Authorization may be terminated
earlier upon written notice from OWCP. For extension of the authorization to treat beyond the
120 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, MRls, 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

OR PHYSICIAN DISPENSED MED/CA T/ONS BILLED WITH
OR OPIOID MEDICATION OR PHYSICIAN DISPENSED MEDICATIONS BILLED WITH HCPCS
HCPCS CODES J3490, J3590, J7999, J8499, J8999 OR J9999

CODES J3490, J3590, J7999, J8499, J8999 OR J9999.

•

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 Volunteer as necessary.

REPORTS

•

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. 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.qov/owcp/dfec.

•

If a Volunteer 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-15.

•

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-15. 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

TAX IDENTIFICATION
NUMBER

CA-15
XX-XX)
CA-15 PAGE
PAGE 5
5 (Rev.
(Rev. XX-XXXX)

ADDITIONAL
INFORMATION

REQUESTS FOR
ACCOMMODATIONS OR
AUXILIARY AIDS AND
SERVICES

•
•

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

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 0MB control number. Public reporting burden for this collection of information is estimated to average
fifteen 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 0MB 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
other healthcare providers for use in providing treatment or
services. (5) Information may be disclosed to physicians and
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-15 PAGE 6 (Rev. XX-XXXX)