CA-20 - Attending Physicianˇs Report

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Attending Physician's Report

0MB No. 1240-0046
Expires: 08/31/2026

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Prinn U.S. Department of Labor

Office of Workers' Compensation Programs

1. Patient's name (last, first, middle):

4. Date of this
Examination:

3. Date of Initial
Treatment:

2. OWCP File No.
(if available):

5. How did the patient's injury occur?

6. Objective Findings (Include physical examination findings and diagnostic test results). Please also discuss pre-existing condition(s) in the affected body
part(s), if any:

7. Medical Diagnosis(es): Please note that "pain" is not a compensable diagnosis; you may however note pain in box 6
above as a symptom of a specific diagnosis or diagnoses.

8. ICD Code(s):

9. Do you believe the condition(s) found was caused or aggravated in any way by an employment activity as described in box 5?
Please note that there is no apportionment under the FECA. Any contribution from work factors is compensable. However, you must explain how the
work activity or workplace incident was sufficient to have caused or aggravated the diagnosed conditions for your response to be accepted.

10. Please check the patient's current disability status:

D Totally Disabled D Partially Disabled 0 Not Disabled

If Totally Disabled.

Date disability commenced:

Date of anticipated return to full or modified work:

If Partially Disabled.

Date disability commenced:

Date of anticipated return to full duty work

Also. complete Box 11.

If Not Disabled. Was there any disability in the case?

If so, indicate dates of disability:

From

to

11. If the patient is partially disabled, indicate the extent of physical limitations and the type of work that could reasonably be performed with these limitations.
You may also complete Form OWCP-5c, Work Capacity Evaluation, which can be found at
https://www.dol.gov1sitesldolgov/files/owcp/dfec/regs/compliance/owcp-5c.pdf

12. Remarks:

Signature

13. I certify that the statements in response to the questions asked above are true, complete and correct to the best of my knowledge. Further, I
understand that any false or misleading statements or any misrepresentation or concealment of material fact which is knowingly made may
subject me to criminal prosecution.
Signature of Treating Provider:______________________________ Date
If treating provider is not a physician (i.e. nurse, physician's assistant), a co-signature from a physician is required below)
Signature of Physician: -------------------------------- Date
14. Name of Physician:
Address:

CA-20 (Revised 08/2023)

15. Tax ID Number
City

State

ZIP:

16. Do you specialize?

□

Yes

D No

17. If yes, indicate specialty:

0MB No. 1240-0046
Expires: 08/31/2026

Box 13

Please sign and date the form. If you are not a physician, a physician must co-sign and date the form as well. Under the
FECA, medical evidence must be submitted by a qualified physician. Nurse practitioners and physician assistants are not
considered qualified physicians under the FECA unless the medical report is countersigned by a physician. A "physician"
includes clinical psychologists acting within the scope of their practice. Also, under the FECA, a "physician" includes
chiropractors only if there is a diagnosed spinal subluxation and it is demonstrated by x-ray.

Box 14-17

Please provide the name, address and tax identification number of the physician signing the form. If the physician is Board­
certified in a particular specialty, please indicate such and provide the specific specialty in Box 17.

Please send the completed form and bill to:

Office of Workers' Compensation Programs
Division of Federal Employees' Compensation
(OWCP- DFEC)
PO Box 8311
London, KY 40742-8311
NOTE - To expedite the processing of this patient's claim, you can concurrently upload this form directly into their case file using the
Employees' Compensation Operations and Management Portal (ECOMP). You can access ECOMP from any internet browser at:
https://www.ecomp.dol.gov/
When you access the website, choose the "Upload Document" option. You will be asked to provide the patient's case number, last
name, date of birth and date of injury to upload a document. ECOMP will then provide you with a Tracking Number so that you can
verify when OWCP has received the CA-20. For more detailed information about this document submission feature, visit the ECOMP
website and click "Help."
Important Notes:
A medical report is required by OWCP before payment of compensation for loss of wages or permanent disability can be made to the
employee.
This information is required to obtain or retain a benefit (5 U.S.C. 8101, et seq.).
OWCP requires that medical bills, other than hospital bills, be submitted on the American Medical Association health insurance claim
form, HCFA 1500/OWCP-1500.
Notice:

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 the OWCP claims examiner to ask about this assistance.

CA-20 (Revised 08/2023)

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