Form CA-20, Attending Physician's Report Instructions
This form contains 34 fields organized into 12 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Information | ||
| Enter remarks | Text |
Enter any additional remarks or comments regarding the patient's condition or treatment.
|
| Disability Dates | ||
| If Totally Disabled, enter the date disability commenced, in the format MM/DD/YYYY | Text |
If the patient is totally disabled, enter the date when the disability commenced in the format MM/DD/YYYY.
|
| If Totally Disabled, enter the date of anticipated return to full or modified work, in the format MM/DD/YYYY | Text |
If the patient is totally disabled, enter the anticipated date of return to full or modified work in the format MM/DD/YYYY.
|
| If Partially Disabled, enter the date disability commenced, in the format MM/DD/YYYY. Then, complete box 11 | Text |
If the patient is partially disabled, enter the date when the disability commenced in the format MM/DD/YYYY. Then, complete box 11.
|
| If Partially Disabled, enter the date of anticipated return to full duty work, in the format MM/DD/YYYY. Then, complete box 11 | Text |
If the patient is partially disabled, enter the anticipated date of return to full duty work in the format MM/DD/YYYY. Then, complete box 11.
|
| If Not Disabled, was there any disability in the case? If so, indicate dates of disability. Enter the from date here, in the format MM/DD/YYYY | Text |
If the patient is not currently disabled but had a period of disability, enter the start date of that period in the format MM/DD/YYYY.
|
| If Partially Disabled, enter the date of anticipated return to full duty work, in the format MM/DD/YYYY | Text |
If the patient is partially disabled, enter the anticipated date of return to full duty work in the format MM/DD/YYYY.
|
| Disability Details | ||
| 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.gov/sites/dolgov/files/owcp/dfec/regs/compliance/owcp-5c.pdf | Text |
If the patient is partially disabled, describe 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.
|
| Disability Status | ||
| form1[0].page1[0].RadioButtonDisabilityStatus[0]_0 | ComboBox |
Select the appropriate disability status.
|
| form1[0].page1[0].RadioButtonDisabilityStatus[0]_1 | ComboBox |
Select the appropriate disability status.
|
| form1[0].page1[0].RadioButtonDisabilityStatus[0]_2 | ComboBox |
Select the disability status of the patient. Options may include Totally Disabled, Partially Disabled, or Not Disabled.
|
| Form Actions | ||
| Click this button to print the form | Button |
Click this button to print the form.
|
| Click this button to reset the form. All field data will be erased | Button |
Click this button to reset the form. All field data will be erased.
|
| Injury Details | ||
| How did the patient’s injury occur | Text |
Describe how the patient's injury occurred.
|
| 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 | Text |
Indicate whether you believe the condition(s) found was caused or aggravated by an employment activity as described. Explain how the work activity or workplace incident was sufficient to have caused or aggravated the diagnosed conditions.
|
| Medical Findings | ||
| 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 | Text |
Provide objective findings including physical examination results and diagnostic test results. Discuss any pre-existing conditions in the affected body parts, if any.
|
| 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 | Text |
Enter the medical diagnosis(es). Note that 'pain' is not a compensable diagnosis but can be noted as a symptom of a specific diagnosis.
|
| Enter ICD Code(s) | Text |
Enter the ICD Code(s) for the diagnosis(es).
|
| Medical Information | ||
| Was there any disability in the case | Text |
Indicate whether there was any disability in the case by providing relevant details.
|
| Patient Information | ||
| Attending Physician’s Report. OMB Number. Expiration date. U.S. Department of Labor. Office of Workers' Compensation Programs. DOL seal. Enter patient’s name (last, first, middle) | Text |
Enter the patient's name in the format: last, first, middle.
|
| Enter OWCP File Number (if available) | Text |
Enter the OWCP File Number if available.
|
| Physician Information | ||
| Enter Name of Physician | Text |
Enter the full name of the physician who is completing this report.
|
| Enter physician's tax ID number | Text |
Enter the tax ID number of the physician. This is typically the physician's Employer Identification Number (EIN) or Social Security Number (SSN).
|
| Enter Physician's address | Text |
Enter the complete address of the physician, including street name and number.
|
| Enter zip code of physician's address | Text |
Enter the zip code corresponding to the physician's address.
|
| Choose state of physician's address | ComboBox |
Select the state where the physician's address is located from the provided list.
AR
FL
ID
MP
PA
SC
GU
AL
NH
NJ
WV
MS
VI
WY
CO
OH
WA
SD
WI
CA
ME
PR
OR
IN
MN
AK
TN
HI
MT
KY
PW
AZ
KS
RI
NM
LA
VT
IL
ND
VA
NE
AS
NC
DE
OK
CT
IA
MA
TX
DC
GA
MO
NV
MI
NY
UT
MH
MD
FM
|
| Enter city of physician's address | Text |
Enter the city where the physician's address is located.
|
| form1[0].page1[0].specializeradiobutton[0]_0 | ComboBox |
Select this radio button if the physician has a specific specialty. This is part of a group of radio buttons to indicate the physician's specialty.
|
| form1[0].page1[0].specializeradiobutton[0]_1 | ComboBox |
Select this radio button if the physician has a different specialty. This is part of a group of radio buttons to indicate the physician's specialty.
|
| Indicate specialty here | Text |
Indicate the physician's specialty in this field. For example, 'Orthopedic Surgeon' or 'General Practitioner'.
|
| Provider Information | ||
| Signature. 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. Enter date of signature of treating provider, in the format MM/DD/YYYY. If treating provider is not a physician (i.e. nurse, physician’s assistant), a co-signature from a physician is required below) | Text |
Signature of the treating provider certifying the accuracy of the information provided. Enter the date of the signature in the format MM/DD/YYYY. If the treating provider is not a physician, a co-signature from a physician is required.
|
| 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. Enter date of signature of physician in the format MM/DD/YYYY | Text |
If the treating provider is not a physician, a co-signature from a physician is required. Enter the date of the physician's signature in the format MM/DD/YYYY.
|
| Treatment Information | ||
| Enter date of Initial Treatment in the format MM/DD/YYYY | Text |
Enter the date of initial treatment in the format MM/DD/YYYY.
|
| Enter date of this Examination in the format MM/DD/YYYY | Text |
Enter the date of this examination in the format MM/DD/YYYY.
|