Complete side a and refer the form to the physician to complete side b. If employee has obtained medical care following the recurrence, list the sources of such care. Also complete the replacements authorized lunch and break locations. Ensuring that the injured worker gets the proper claim forms, especially the ca 16, can prevent major claim prob lems in the future. Nimphius reported the accident to his immediate supervisors. For a recurrence more than 90 days after the employees return to work, owcp must authorize further medical care. Form ca16 is valid for up to sixty days from date of issuance, and may be terminated earlier upon. Within one working day after you file the claim form, your employer must complete the employer section, give you a dated copy, keep one copy, and send. City state zip code form ca 1 revised october 2018.
Call federal workers compensation consultants today for a free initial consultation at 89311984. The injured employee should request a form ca 16 and identify the physician that has been selected to provide medical treatment for the injury. Ca16 authorization for examination andor treatment. Fill in the address of the employing agency and the appropriate owcp district office in the spaces below. When an injured employee is seen or treated by either a postal medical officer or contract doctor for a first aid case not reportable to owcp district office who prepares a. If you have any questions feel free to contact our department at 7147481100. Your supervisor should complete page 1 of form ca 16 and provide it to you for your attending physicians information. Form ca 1 this form was electronically produced by national production services staff rev. Form ca16 is valid for up to sixty days from date of injury, and may be terminated earlier upon written notice from owcp tothe provider. As the time the form is received, complete the receipt of notice of injury and give it to the employee. Claim of right to possession and notice of hearing cp10 rev. You should present this form to your attending physician and request that they complete page two of the form and forward it. Statement ol witness describe what you saw, heard, or know about this injury name of witness signature of witness address city date signed zip code form ca 1 revised january 20. Personnel licensing, aviation safety operations form number.
Source for all postal workers and employees for postal news, postal forums, postal resources, postal benefits, and much more. All of dfecs online forms with the exception of forms ca 16, ca 26 and ca 27 are available to print and to manually fill and submit. If you are claiming a recurrence of disability for an occupational illness, or if all 45 days of continuation of pay cop have been used, you may claim wage loss on form ca 7. Form 16 1 authorization for use or disclosure of health information 304 california hospital association page 1 of 3 completion of this document authorizes the disclosure and use of health information about you.
A physician who is debarred from the feca program as provided at 20 cfr 10. This form is only available to authorized employing agency personnel, and may be obtained in electronic format via the agency query system aqs or ecomp, or by contacting the employing agency workers compensation personnel. The employee delivers this form, along with the ca 16, job descriptions, and owcp form 1500 as appropriate, to the treating physician. What history of injury or disease did employee give you. When an injured employee is seen or treated by either a postal medical.
Postal employees postal workers injured on duty information. The form should be promptly referred to the attending physician for early completion. Ca 16 authorization for examination andor treatment 543. Form ca 16 authorization for examination andor treatment. Is there any history or evidence of concurrent or preexisting injury, dis ease, or physical.
Simply click on the appropriate form and print it using the print button provided near the top of the form. Forms division of federal employees compensation dfec. Authorization for examination andor officetreatment. Form ca 16 this form was electronically produced by national production services staff rev. Postal service has an obligation to provide forms necessary to file the claim ca 1, ca 2, receive medical treatment ca 16 and in form the treating physician of the letter carriers work duties ca 17. For traumatic injuries, ask your employer to authorize medical treatment on form ca 16 before you go to the doctor. Name position title home installation employee id employee official tour flsa worksheet if temporary assignment includes hours outside of paid flsa work week, enter flsa. An employees guide on reporting a workrelated injury or. It should not be used to authorize a change of physicians after the initial choice is exercised by the employee. The agent provides the original completed signed ps form 1583 to the postal. All categories applications beneficiary forms for usps employees centralized account processing system caps confirmation services employment firstclass mail, priority mail and priority mail express international miscellaneous ordering package. Statement of witness describe what you saw, heard, or know about this injury name of witness.
Highways satements t deposit ed or declarations lodged prior to 1 october 20 continue to have effect. Here youll find all the forms necessary to handle your business mailing needs. Form ca 16 is valid for up to sixty days from date of issuance, and may be terminated earlier upon written notice from owcp to the provider. All work practices needing improvement and noted below should be discussed with the employee as soon as possible after the observa. Form ca 1 is to be used by clearing agencies, as defined in section 3a23 of the act, which perform the functions of a cle aring agency with respect to any security other than an exempted security, as defined in section 3al2 of the act, to apply for.
In the event the physician forwards the ca 20, or an acceptable narrative report directly to the owcp, a copy of the same should be requested from either the owcp or from the employee. Signature of applicant if firm or corporation, application must be signed. If you mail the form to your employer, use firstclass or certified mail. Statement of witness describe what you saw, heard, or know about this injury. Name and address of reporting office include city, state, and zip code. Ps form 1723, december 2008 psn 7530020007366 assignment order current assignment new directed assignment to. The treating physician will complete side b of the form and either give it, along with the approved job descriptions, to the employee for immediate return to the icco or, if necessary, mail to the icco in the.
If claimant has obtained medical care for the recurrence prior to completing the form, all dates of treatments and therapy should be listed. I declare under penalty of perjury under the laws of the state of california that the foregoing is true and correct. Have our su ervisor com lete this recei t attached to this form and return it to 16. Omb 30460046, demographic information on applicants form. Select a category to limit the listing to a specific form type. The opm forms management program web site serves as the single source of information for forms belonging to and used by the office of personnel management. The national association of letter carriers nalc is the national labor union of city delivery letter carriers employed by the united states postal service. Cp10 claim of right to possession and notice of hearing. Ca 1, ca 2 traumatic injuries occupational injuries illness filed on form ca 1 ca 2 forms needed for doctor form ca 16 authorization for treatment form ca 17 duty status report, i. Owcp form ca 20 instructions continued authorize coplwopiod, and to return the employee to limited duty or full duty at the earliest possible time. Form ca 16 is valid for up to sixty days from date of injury, and may be terminated earlier upon written notice from owcp tothe provider. An employees guide on reporting a workrelated injury or disease. After routing letters, flatsize mail magazine or mail too large for letter casing is routed into a 4 or 5 shelf l shaped mail case, with up to 360 vertical separations, which are in route. The letter carriers supervisor is responsible for completing some portions of each form.
This form, when used correctly, can aid in the elimination of work practices which cause accidents. All postal installations are required to have form ca2 s available. Federal employees notice of traumatic injury and claim. Form 16 1 authorization for use or disclosure of health information 3 california hospital association page 1 of 3 completion of this document authorizes the disclosure and use of health information about. If ca 16 was issued, identify physician listed in item 1 of the ca. This requires the postal service to issue a form ca 16 within 48 hours. Ca 1 federal employees notice of traumatic injury and claim for continuation of paycompensation. Letter carrier duties daily physical operations sorting. The ca 17 is a form which the owcp directs both the injured workers supervisor and hisher treating physician to complete. For recurrences of disability which continue after the 45 days of cop have expired or which involve occupational illness, instruct the employee to file form ca 7. Ps form 1564a,march 1986 3enter name of regularly assigned replacement if any. These supervisors did not provide him with form ca 1 and form ca 16 as postal service rules and regulations require. In order to prevent any of your land being recorded on the definitive map as a highway, you must lodge a further highways declaration within each successive 20 year period thereafter.
A ca2 is the proper form for you to file a claim for occupational disease or illness. Department of labor office of workers compensation programs duty status report this form is provided for the purpose of obtaining a duty status report for the employee named below. A prejudgment claim of right to possession form was not served with the summons and. Ca1 federal employees notice of traumatic injury and. Per instructions on the form and the usps policy, this is the identification and address of the control office authorized to communicate with the district. If possible, the injured worker should take the ca 16 when first going to the doctor. Lets start with a brief discussion of the ca 17 duty status report, what types of information are contained on it, and who completes the form. This request does not constitute authorization for payment of medical expense by. In addition to completing items 17 through 39, the supervisor is responsible for obtaining the witness statement in item 16 and for filling in the proper codes in shaded boxes a, b, and c on the front of the form. All of dfecs online forms with the exception of forms ca16, ca26 and ca27. Ikhaya lokundiza, 16 treur close, waterfall park, bekker street, midrand, gauteng postal address.
It should not beused authorize a change of physicians after the initial choice is exercised by the employee. Send your medical report directly to owcp and not to the postal service. Have your supervisor complete this receipt attached to this form and return it to you for your records. Ca7, claim for compensation benefits nalc branch 908. Write or type the required information on the hardcopy and authorize the form, if applicable, with a. Take form ca 16 when you go to the doctor, along with form owcp1500, which. Claim for medical reimbursement form owcp915 replaces ca 915. For claims based on traumatic injury and reported on form ca 1. Department of labor andor treatment employment standards administration office of workers compensation programs the following request for information is required under 5 usc 8101 et. In order to view andor print pdf documents you must have a pdf viewer.
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