Attachment 14 CA16.pdf

Authorization for Examination u~s. DeDartment of Labor Employment ~tandard9 AdministrationAnd/Or Treatment Office of Workers' COmpensation Programs

The fO"owing request tor Information is aulhor1zed by law (5 USC 9101 et. seq.). Benefits am:Uor ITKIdlcal services OMS NO.; 1215-0103 expenses may not be paid or may be subjeot to suspension under this program unless this report Is completed and filed as Expire!'!; 09-30-91 r9QU9sted. Information COllected will be handled and stored In compliance with the Freedom of Infonnatlon Aot. the PriVacy Act of 1974 and OMS Cir. No. A-1M.

PART A.. AUTHORIZA"ON

1. Name and Address of the Medical Facility or Physician Authorhted to Provide the Medical Service:

2. Employee's Name (last, first, middle) 3. Date of InJulY (mo. day. yr.) 4. Occupation

5. OElscrlption of Injury or 0lgeaS8

6. You are authorized to provide medical care for the employee for a period of up to sixty days from the data shown in Item 11, subject to the condition stated In Item A. and to the oond'rtion indicated either 1 or 2. In item B.

A. Your sIgnature mitem 35 of Part B oertifias your agreement that all fees for sarvlces shall not exceed the ma><imum allowable fee established by OWCP and that PQyment by OWCP wn! be accepted as pe.yment in full for said servk:9s.

6. 0 1. Furnish office al"ldlor hospital treatment as medically necessary for the effgc\s of thl9 injury. Any surgery other than srooTgQnoy must have prior OWCP approva.l.

There is doubt whether the employ08e's condition Is cauaed by an Injury 8ustalnedln the pel'fonnanco of duty, or is otherwiSe related to the employment. You are authorized to examine the employee using indicated non-surgical dil!lgnostio llItudles, and promptly advise the undersl!Jled whether you believe the condition lSI due to !hI! alleged Injury or to any Ciroumstances of the employment. Pendmg furtlier advice you may provide I1SCessa!'y conservative treatment if you believe the condition may be to the Injury or to the employment.

7. If a Disease or Illness is inVOlved, OWCP Approval for Issuing Authomation was ObtaIned frOm; (Type Name and TiUe of OWe? Off1clsJ)

S. Signature of AUlhmiiting Official:

&. Name and 1111e of Authorizing Offiolal: (Type or print clearly)

10. Local Employing Aggncy Telephone Number. 11. Date (mo., day, year)

12. Send one copy of your report (Fill in remainder of address) 13. Name and Address of Employee's Place of Employment:

OeparttnentofAgency

U.S. DEPARTMENT OF LABOR

Employment Slandan::!l(1 Administration Office of Workers' Oompensallon Programs

Bureau or OffIce

Local Address (including Zip Code)

Public BUrden Statement

Public reporting burd9!l for thIs oollectlon of Infonnation Is aatimated to avemge 30 minutes p9r response. including Ume tor revi8wlng Instructions ~l'Qhing exlstin~ data sources, Qli1h9r1ng and maIntaining the data needed, and compl~g and reviewing the Collection of Information. Send ooml'Tl9l'lt8 regarding !he bUrden estimate or any other aspect of thl$ COllection Of Information. Including suggeetions for redUCing burden, to the OffIce of InformIl.Ilon Management. C~rtm9l'lt of Labor, Room N1301, 200 Constftution Avenue, N.W., WaShlilgton, D.C. 20210' and to the OffIce of Information and Regulation Affairs. OffIce of Management fmd Budget, WaShington, D.C. 20503. '

FormCA·16 Rev. Od 1988

C002473 Typewritten Text

ATTACHMENT 14

PART B " ATTI!!NDING PHYSICIAN'S REPORT

14. Employee'! Name (last, first, mlddla)

15. Wtlat Hiatol'y of Injury or Disease Old Employee Give You?

16a. 100·9 CODE16. Is there any Hi&tol'y or Evidence of Concurrent or Pre-existing InJury> Disease, or Physleallmpairment?

L .L t I I I IDYes 0 No 18a. ICD-9 COOl! ..... .17. What are Your Findings? (include results of XoI"QYS, laboratory tests. etc.) 18. What Is your diagnosis?

19. 00 YOU Belisve the Condition Found was Caused or Aggravated by the Employment Activity Desorlbed? (Please explain your answer if there is doubt) o Ves 0 No

20. Old Injury Require Hospitalization? U Yes If yes. date of admission (mo.• day. year) Date of discharge (mo., day, year)

U No 2'1. Is Additional Hospitalization ReC4ulred?

DYes D No

22. Surgery (If any. describe type) 23. Date Surgery Perfol1ll9d (mo. day. yr.)

24. What (Other) Type of Treatment Old Vou Provide? 25. What Pennenant Effects, if Any, Do You Anticipate?

26. Date of First Examination (mo. day, yr.) 127. Dote(s) of Treatment (mo. day, yr.) .128. Oelte of Discharge from Trootment (mo. day, yr.)

29. Period of Disability (mo. day, yr.) {If termination date unknown, $0 80. Is Employee Able 1:0 Resume indicate} Total DlsabHity; From To 0 Ught Work Oate:

PartlalOiaabillty; From To Regular Work Date:

_D

31. If employoo Is Able to Resume Work, Has Ha/She been Advised? U Ves U No If Yes, Fumlsh Date Advised

32. If Emp!oyee ;$ Able to Rse.ume Only Light WOrk, IndlcQte the Extent of Physical limitations and the Type of Work that Could ROOSOI'Iably be Performed with these LimitatlOl'l$,

33. General Remarks and Recommendations for Future Care, if indicatad. If you have made a Referral to Another Physician Of to Q Medic:ai Facility. Provide Name and Addmss.

34. 00 You Specialize? o Yee o No (If yes, state specialty)

35. SIGNATURE OF PHYSICIAN. I oertify that all the statements In 36. Address (No•• Straet, City. State. Zip Coda) response to the questions asked In part B of this form are true, complete and correct to the ba$t of my knoWlBdge. Further, I understand that any false or misleading statement or any misrepresentation or concealment of material fact which Is knowIngly moos may subjeot me to felony cr'fmlnal pl'I)$ectJtIon. 37. Tax IdentifICation Number 38. Data of Report

MEDICAL BILL: Charges for your services should be prooentad to the AMA standard "Health ln$ural1C9 Claim Fonn" (AMA OP 407/408/400;

OWCP-1 SOOfl, or HCFA 1500). Service mU$t be ltemi;:ed by Cyrrent Procedural Terminology Code (CPT 4) and the form must be signed.

For sale by the Supel'lrdsndMt of Coeul'tle!lll!.t U.S. Government Pl'lnllng Offtce. WAshington, O.C. 2040Z

C002473 Typewritten Text

ATTACHMENT 14