DoL CA-16 2005 free printable template

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE Form CA-16 Rev. Feb. 2005 PART B ATTENDING PHYSICIAN S REPORT 15. ADDITIONAL INFORMATION See 20 CFR and/or Chapter 810 Federal Personnel Manual FPM Information for Physician See Reverse Side YOUR Please read Part A of Form CA-16. If the employee elects to be treated by a private physician a copy of the American Medical Association standards billing form AMA OP 407/408/409 OWCP-1500a should be supplied together with Form CA-16. The supervisor...

How to fill out form ca 16 2005-2019

How to fill out DoL CA-16

1. Obtain a copy of the DoL CA-16 form from the Department of Labor website or your employer.
2. Fill out the employee's information section, including name, address, and contact information.
3. Provide details about the incident, including the date, time, and nature of the injury or illness.
4. Complete the section for the supervisor's information and any witnesses to the incident.
5. Sign and date the form to certify the accuracy of the information provided.
6. Submit the completed CA-16 form to your supervisor or designated claims official.
7. Ensure that a copy of the form is retained for your records.

Who needs DoL CA-16?

1. Any federal employee who suffers a work-related injury or illness can request a DoL CA-16 to expedite medical care and services.

Instructions and Help about form ca 16 2005-2019

Form CA 16 provides authorization to the employee for immediate examination in treatment the form should be provided to the employee by the supervisor within four hours of the time that the injury is claimed once the employee has formed CA 16 they have a median authorization to get examination and treatment for the on-the-job injuries that they have sustained that authorization remains good for 60 days that way you can go ahead go to the hospital or doctor of your choice and get the MRIs the testing or the treatment that you may need to support your claim that CA 16 however must be requested by you, and it must be done within one week, or it will probably not be allowed under the federal employee compensation act so act quickly do it the first day if at all possible

People Also Ask about

Who fills out a ca16?

Your supervisor should complete page 1 of Form CA-16 and provide it to you for your attending physicians information. You should present this form to your attending physician and request that they complete page two of the form and forward it to the OWCP.

What is a ca1 form?

The CA-1 form is used if the employee has sustained a Traumatic Injury on the job. Traumatic Injury - A wound or other condition of the body caused by external force, including stress or strain.

What is a ca3 form?

Report of Termination of Disabilty. and/or Payment. U.S. Department of Labor. Form CA-3.

When can CA-16 be issued?

A CA-16 can be issued up to 48 hours after the employee has been treated. If the employee provides a medical report within 48 hours or treatment indicating the condition is work-related, a CA-16 can be issued with supervisory approval.

How do I get a CA-16?

CA-16s can be approved and provided only by a postal supervisor. A properly issued CA-16 must have the name, title and signature of the authorizing official. CA-16s are not available online—for a very good reason. Only the au- thorizing agency has the authority to provide the CA-16.

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What is DoL CA-16?

The DoL CA-16 is a form used by the Department of Labor (DoL) to obtain medical information necessary for the evaluation of a claim for benefits under the Federal Employees' Compensation Act (FECA).

Who is required to file DoL CA-16?

The DoL CA-16 must be filed by federal employees who have sustained injuries or illnesses that are believed to be work-related and are seeking compensation or medical benefits under FECA.

How to fill out DoL CA-16?

To fill out DoL CA-16, the claimant must provide detailed information regarding the injury, including the date, time, and conditions under which the injury occurred, as well as personal information and medical treatment received.

What is the purpose of DoL CA-16?

The purpose of DoL CA-16 is to collect relevant medical data from healthcare providers to support a claim for worker's compensation benefits under FECA.

What information must be reported on DoL CA-16?

The form requires information such as the claimant's personal information, details about the injury or illness, medical treatment received, and any other relevant medical history that pertains to the claim.