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Form CA-20, Attending Physician's Report, page 1
Moderate · 47/100Form Complexity Index

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What this form asks for

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Form CA-20, Attending Physician's Report, is a document used by physicians to report on a patient's medical condition related to a work injury. This form is crucial for the Office of Workers' Compensation Programs to assess claims and determine eligibility for benefits.
Fillable fields34
Pages1
Sections12
Form Complexity IndexModerate, 47/100

The AI checks your answers before you download

15 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Ensures that the patient's full name is entered correctly in Box 1.

The AI ensures that the patient's full name is accurately captured in Box 1 of the Attending Physician's Report. It checks for any typographical errors, misspellings, or formatting inconsistencies that may have occurred during the data entry process. The AI cross-references the entered name with other official documents provided to confirm its correctness. It also ensures that the name is complete, including any middle names or initials, as per the form's requirements.

Verifies that the OWCP File Number is entered in Box 2 if available

The AI verifies the presence of the Office of Workers' Compensation Programs (OWCP) File Number in Box 2. If the number is available, the AI checks for the correct format and sequence of digits or characters. In the absence of an OWCP File Number, the AI confirms that Box 2 is intentionally left blank and not due to an oversight. It also ensures that no placeholder or incorrect information is entered in place of the actual file number.

Confirms that the date of initial treatment for the work injury is accurately entered in Box 3.

The AI confirms that the date of initial treatment for the work-related injury or illness is accurately recorded in Box 3. It validates the date format according to the form's specifications and checks for logical consistency with the timeline of reported events. The AI also ensures that the date entered is plausible and falls within a reasonable timeframe after the reported injury or illness occurred.

Checks that the date of the examination upon which the findings are based is correctly entered in Box 4.

The AI checks that the date of the medical examination, which forms the basis of the report's findings, is correctly entered in Box 4. It ensures that the date is in the correct format and is logically consistent with the dates of injury and initial treatment. The AI also verifies that this date is not in the future or before the date of injury, ensuring chronological accuracy.

Validates the detailed description of how the patient's injury or disease occurred in Box 5.

The AI validates the detailed description provided in Box 5, which explains how the patient's injury or disease occurred. It checks for completeness and clarity of the narrative, ensuring that it contains sufficient detail for an understanding of the incident. The AI also looks for any inconsistencies with known facts of the case and verifies that the description aligns with the type of injury or disease reported.

Ensures that objective findings from the physical examination and any diagnostic tests are detailed in Box 6, including any pre-existing conditions.

The system ensures that Box 6 of the Attending Physician's Report is thoroughly completed with objective findings from the physical examination and any diagnostic tests. It checks for the inclusion of detailed descriptions of the patient's condition, ensuring that any pre-existing conditions are also mentioned. The validation process involves cross-referencing the provided information with standard medical examination protocols to confirm that all necessary details are captured accurately and comprehensively.

And 9 more checks
  • Confirms that specific medical diagnoses related to the work injury are provided in Box 7 and that 'pain' is not listed as a diagnosis.
  • Verifies that the ICD codes for each diagnosis are correctly listed in Box 8.
  • Assesses the explanation in Box 9 regarding whether the condition(s) found were caused or aggravated by employment activity.
  • Confirms the patient's current disability status is circled in Box 10, with relevant dates for disability commencement and anticipated return to work provided.
  • Physical Limitations Indication
  • Additional Remarks Provision
  • Provider and Physician Signatures
  • Physician Information Accuracy
  • Form Submission Protocol

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How to Fill Out CA-20 Online for Free in 2026

What the AI walks you through.

  1. Visit instafill.ai site and select Form CA-20.
  2. Enter patient's full name in Box 1.
  3. Fill in OWCP File Number if available.
  4. Provide dates of treatment and examination.
  5. Detail injury occurrence and objective findings.
  6. Sign and date the form electronically.
  7. Check for accuracy and submit the form.

Common Mistakes in Completing CA-20

The ones the AI is built to catch.

Omitting or providing incomplete information in Box 1 (Patient's full name)
The Attending Physician's Report requires the complete and accurate patient's name to be entered in Box 1. Leaving this field blank or incomplete can lead to processing delays or potential misidentification of the patient. To avoid this mistake, ensure that the patient's full name, including middle initial if applicable, is entered correctly and completely. Double-check the spelling and formatting of the name to ensure accuracy.
Entering an incorrect OWCP File Number in Box 2
The OWCP File Number is a critical piece of information required for processing the Attending Physician's Report. Entering an incorrect number can lead to significant delays or even denial of the claim. To avoid this mistake, double-check the OWCP File Number provided by the employer or insurance company and ensure it is entered correctly in the designated field.
Incorrectly entering the date of initial treatment or examination in Boxes 3 and 4
The dates of initial treatment or examination are essential pieces of information required for processing the Attending Physician's Report. Incorrectly entering these dates can lead to processing delays or potential denial of the claim. To avoid this mistake, ensure that the dates are entered accurately and in the correct format (MM/DD/YYYY) in the designated fields.
Vaguely describing the injury or disease in Box 5
Providing a vague description of the injury or disease in Box 5 can lead to processing delays or potential denial of the claim. To ensure accurate processing, it is essential to provide a clear and detailed description of the injury or disease, including the body part affected and the nature of the injury or disease.
Failing to provide detailed objective findings in Box 6
The Attending Physician's Report requires detailed objective findings to support the diagnosis and treatment of the injury or disease. Failing to provide this information can lead to processing delays or potential denial of the claim. To avoid this mistake, ensure that all relevant objective findings are documented in Box 6, including symptoms, physical findings, and any diagnostic tests or procedures performed.
Misdiagnosing or using non-specific diagnoses in Box 7
The Attending Physician's Report requires precise and accurate diagnoses in Box 7. Misdiagnosing a condition or using non-specific diagnoses can lead to confusion and potential delays in processing. To avoid this mistake, physicians should ensure they provide the exact and most current diagnosis based on their clinical evaluation and medical records. It is essential to use specific and clear diagnoses to help accurately assess the claimant's condition and determine eligibility for benefits.
Failing to provide ICD codes for each diagnosis in Box 8
ICD codes are required for each diagnosis listed in Box 8 of the Attending Physician's Report. Failing to provide these codes can result in processing delays and potential errors. To avoid this mistake, physicians should ensure they have the correct ICD codes for each diagnosis and include them in the report. It is essential to use the most recent and specific codes to help accurately assess the claimant's condition and determine eligibility for benefits.
Incorrectly stating that the condition was not caused or aggravated by employment activity in Box 9
Box 9 of the Attending Physician's Report requires physicians to indicate whether the condition was caused or aggravated by employment activity. Incorrectly stating that the condition was not caused or aggravated by employment activity can lead to denial of benefits. To avoid this mistake, physicians should carefully consider the medical evidence and their clinical evaluation when completing this section. They should document any relationship between the condition and employment activity, even if it is minimal.
Circling an incorrect disability status in Box 10
Box 10 of the Attending Physician's Report requires physicians to indicate the disability status of the claimant. Circling an incorrect disability status can lead to processing delays and potential errors. To avoid this mistake, physicians should carefully review the medical evidence and their clinical evaluation when completing this section. They should ensure they select the correct disability status based on the claimant's condition and functional limitations.
Failing to provide specific physical limitations in Box 11
Box 11 of the Attending Physician's Report requires physicians to provide specific physical limitations. Failing to provide this information can lead to processing delays and potential errors. To avoid this mistake, physicians should carefully document the claimant's physical limitations and include them in the report. They should use specific and measurable language to help accurately assess the claimant's condition and determine eligibility for benefits.
Neglecting to complete Box 12 (Additional remarks) when relevant
The Attending Physician's Report form, also known as TR-2050, includes a Box 12 for additional remarks. This section is crucial for providing any additional information that may not fit into the other sections. Failing to complete this section when necessary can lead to important details being overlooked. To avoid this mistake, ensure that all relevant information is included in the appropriate sections or in Box 12 as needed.
Forgetting to sign and date the form in Boxes 13 and 14 (Treating provider and physician)
Both the treating provider and the physician must sign and date the form in their respective boxes (Boxes 13 and 14). Failure to do so can result in the form being considered incomplete and potentially delayed or rejected. To prevent this mistake, ensure that both parties understand the importance of signing and dating the form in the correct boxes.
Failing to provide complete information in Boxes 14-17 (Physician's information)
Boxes 14-17 on the Attending Physician's Report form require the physician to provide their name, address, phone number, and National Provider Identifier (NPI). Failing to provide complete and accurate information in these sections can lead to delays or errors in processing the form. To avoid this mistake, ensure that all required information is provided in full and that it is legible and easy to read.

Frequently Asked Questions About CA-20

 

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CA-20 has a Form Complexity Index of 47 out of 100, in the moderate tier: 34 fillable fields across 1 page. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What information should be provided in Box 5 regarding how the patient's injury occurred?
Box 5 of the Attending Physician's Report is used to describe how the patient's injury occurred. It is important to provide as much detail as possible about the incident that led to the injury. This may include the date and time of the incident, the location where it occurred, and a description of the events leading up to the injury. It is also important to note any safety precautions that were not followed or any hazards that may have contributed to the injury.
What objective findings and diagnostic test results should be detailed in Box 6?
Box 6 of the Attending Physician's Report is used to document the objective findings and diagnostic test results related to the patient's injury. Objective findings refer to observable and measurable symptoms, such as swelling, bruising, or abnormal lab results. Diagnostic test results may include X-rays, MRI scans, or other imaging studies. It is important to provide as much detail as possible about any tests that were performed and the results of those tests.
What types of medical diagnoses are acceptable in Box 7?
Box 7 of the Attending Physician's Report is used to document the medical diagnoses related to the patient's injury. Acceptable diagnoses may include any condition or injury that is related to the work incident. This may include acute injuries, such as fractures or lacerations, as well as chronic conditions that were aggravated or accelerated by the work incident. It is important to note that the diagnoses must be supported by objective findings and diagnostic test results.
How should the causal relationship between the work injury and diagnoses be explained in Box 9?
Box 9 of the Attending Physician's Report is used to explain the causal relationship between the patient's work injury and the diagnoses. It is important to provide a clear and concise explanation of how the work incident contributed to the patient's injuries or diagnoses. This may include a description of the mechanism of injury, the sequence of events leading up to the injury, and any objective findings or diagnostic test results that support the causal relationship.
What is the difference between direct causation, aggravation, acceleration, and precipitation in Box 9?
In Box 9 of the Attending Physician's Report, it is important to distinguish between different types of causal relationships between the work injury and the diagnoses. The following definitions may be helpful: * Direct causation: The work injury was the sole cause of the patient's diagnoses. There would be no diagnoses if the work incident had not occurred. * Aggravation: The work injury made an existing condition worse. The patient may have had the condition before the work incident, but the injury exacerbated it. * Acceleration: The work injury caused a condition to develop more quickly than it would have otherwise. The patient may have been at risk for the condition, but the work incident brought it on more rapidly. * Precipitation: The work injury was the trigger for the patient's diagnoses, but the condition would have eventually developed on its own. It is important to provide a clear and concise explanation of which type of causal relationship applies to the patient's case.
What should be indicated in Box 10 regarding the patient's disability status and dates?
Box 10 of the Attending Physician's Report is used to indicate the patient's disability status and the dates of such disability. The attending physician should check the appropriate box based on the patient's condition: (1) No work restriction, (2) Work restriction with no wage loss, (3) Work restriction with wage loss, or (4) Death. If the patient has a work restriction, the attending physician should also provide the start and end dates of the restriction.
What should be provided in Box 11 if the patient is partially disabled?
If the patient is partially disabled, the attending physician should provide a description of the patient's condition and the percentage of disability in Box 11. The percentage should be based on the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment, 6th Edition.
What is the purpose of Box 13 and what information should be provided there?
Box 13 of the Attending Physician's Report is used to indicate the attending physician's name, signature, and the date of the examination. The physician should also provide their medical license number and the name and address of their medical practice or facility.
What is the address to send the completed form and bill to?
The completed Attending Physician's Report and any associated bills should be sent to the following address: Office of Workers' Compensation Programs, P.O. Box 6916, Jacksonville, FL 32231-6916.
How can the form be uploaded directly into the patient's case file using the Employees' Compensation Operations and Management Portal (ECOMP)?
To upload the completed Attending Physician's Report and any associated bills directly into the patient's case file using ECOMP, the user must first log into their ECOMP account. Once logged in, they should navigate to the 'Medical' tab and select 'Attending Physician Reports' or 'Bills'. The user can then upload the documents by clicking the 'Add' button and selecting the file(s) to upload. It is important to ensure that the document(s) are in a compatible format, such as PDF or TIFF.
What is the consequence of failing to disclose all requested information in the form?
Failing to disclose all requested information in the Attending Physician's Report (APR) may result in delays or denial of payment for services or benefits. It is important to provide accurate and complete information to ensure proper processing of the claim.
What is the Privacy Act Statement and what information does it cover?
The Privacy Act Statement in the APR is a notice that explains how your personal information will be used and disclosed. It covers information that can be used to identify you, such as your name, address, and Social Security number. The statement also explains your rights under the Privacy Act, including the right to access and correct your information.
What is the Public Burden Statement and what is the estimated reporting burden for this collection of information?
The Public Burden Statement is a notice that explains the estimated time and costs to the public for complying with the collection of information in the APR. The estimated reporting burden for this form is approximately 20 minutes for the completion of the form and the maintenance of records. This estimate may vary depending on the complexity of the case.
What is the difference between a compensable diagnosis and a diagnosis of 'pain' in Box 7?
A compensable diagnosis is a medical condition that is recognized and covered under a particular insurance or benefit program. In Box 7 of the APR, a compensable diagnosis refers to a diagnosis that is related to the injury or illness for which the report is being submitted. A diagnosis of 'pain' is a symptom, not a specific diagnosis. It is important to provide the specific diagnosis related to the injury or illness, if known.
What should be done if the patient has a disability and requires accommodations or auxiliary aids and services?
If the patient has a disability and requires accommodations or auxiliary aids and services to complete the APR, the patient or their representative should contact the appropriate insurance or benefit program to request accommodations. The program may provide alternative formats of the form, such as large print or audio, or may offer assistance in completing the form. It is important to ensure that all necessary information is provided to allow for proper processing of the claim.
What form should be used for work capacity evaluation for orthopedic conditions?
For orthopedic conditions, the Attending Physician's Report (APR) form, also known as the Department of Labor (DOL) Form OWCP-18, is typically used for work capacity evaluations.
What form should be used for work capacity evaluation for psychiatric conditions?
For psychiatric conditions, the Mental Status Questionnaire (MSQ) form, also known as the DOL Form OWCP-19, is typically used for work capacity evaluations.
What form should be used for work capacity evaluation for cardiac conditions?
For cardiac conditions, the Cardiac Consultation Report (CCR) form, also known as the DOL Form OWCP-20, is typically used for work capacity evaluations.
What is the requirement for a physician to sign and date the form in Box 13?
The physician must sign and date the form in Box 13 to certify that they have examined the patient and have provided their professional opinion regarding the patient's work capacity based on the information provided on the form.
What is the difference between a physician and a qualified physician under the FECA in Box 13?
A physician is any person who practices medicine or surgery, or is licensed, certified, or otherwise authorized to practice medicine or surgery by the state in which the services are performed. A qualified physician, as referred to in Box 13, is a physician who is qualified under the Federal Employees' Compensation Act (FECA) to provide medical treatment and make work capacity evaluations for federal employees.
What is the consequence of submitting medical bills on forms other than the American Medical Association health insurance claim form, HCFA 1500/OWCP-1500?
Submitting medical bills on forms other than the HCFA 1500/OWCP-1500 form may result in processing delays or rejections, as the Office of Workers' Compensation Programs (OWCP) may not be able to process claims using forms that are not standardized for their system.
What is the consequence of not providing the patient's case number, last name, date of birth, and date of injury when uploading a document on ECOMP?
Failing to provide the patient's case number, last name, date of birth, and date of injury when uploading a document on ECOMP may result in processing delays or rejections, as the OWCP requires this information to properly identify and process the claim.
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