CA-15 Peace Corps Volunteer Authorization for Examination And/

Peace Corps Volunteer Authorization
for Examination And/Or Treatment

U.S. Department of Labor
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: XX/XX/XXXX

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.
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 13. Remarks (See Instructions under Authorized Official):
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-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)
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 Peace Corps Service 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

To

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

Yes

No

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?

Yes

No

(If yes, state specialty)

35. I certify that all the statements in this form 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
Number

39. Date of Report

38. National Provider
System Number

Printed/Typed Name/Signature of Physician (See Instructions for Definition)
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

• Authorized personnel may include any Office of Health Services staff whose current position
includes duties related to the FECA program.

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.
• 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.

PERIOD OF
AUTHORIZATION

• 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.

FEDERAL MEDICAL
FACILITIES

• 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).

DEFINITION OF
INJURY

• 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
MEDICAL
FACILITY/
PHYSICIAN

• 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.
• The term "physician" includes doctors of medicine (MDs), surgeons, podiatrists, dentists, clinical
CA-15 PAGE 3 (Rev. XX-XXXX)

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 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.

FORM
COMPLETION

• 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.

ADDITIONAL
INFORMATION

• See 20 CFR 10.5

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

USE OF CONSULTANTS
AND HOSPITALS

• 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.gov/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.

TAX IDENTIFICATION
NUMBER

• 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
CA-15 PAGE 5 (Rev. XX-XXXX)

ADDITIONAL
INFORMATION

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

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.

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 services.
(5) Information may be disclosed to physicians and other healthcare providers for use in providing treatment or
medical/vocational rehabilitation, making evaluation for the Office, and for other purposes related tot he medical management of the claim. 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)