Form CA-20 at a glance
What it is: This is the Attending Physician's Report of the U.S. Department of Labor Office of Workers' Compensation Programs.
A filled-in Form CA-20 example: a physician reports a partially disabled patient
How to fill out Form CA-20, box by box
Tap a group of boxes to open it, and a picture to see it full size.
Patient's name, OWCP File No. and the dates
OMB No. 1240-0046 Expires: 09/30/2026. Box 1: Enter the patient's full name (last, first, middle). Box 2: If not prepopulated, enter the OWCP File Number provided to you by the patient; if unknown, leave blank.
Box 3: Enter the first known date this patient sought treatment for the work injury as the Date of Initial Treatment.
Box 4: Enter the date of this examination (i.e. the examination upon which your findings on the form are based) as the Date of this Examination.
How the injury occurred
Box 5: Provide an explanation as to how the patient's injury or disease occurred, and be as specific as possible.
Objective findings
Box 6: Detail the patient's objective findings on physical examination as related to the work injury noted in Box 5, include results of any diagnostic testing performed, and please also discuss pre-existing condition(s) in the affected body part(s), if any.
Medical Diagnosis(es) and ICD Code(s)
Box 7: Provide specific diagnoses of each medical condition connected to the work injury; 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.
Box 8: Provide corresponding ICD codes for each medical condition noted in Box 7.
Was the condition caused by the work injury
Box 9: Address whether the work injury noted in Box 5 is causally connected in any way to the diagnoses in Box 7; note that there is no apportionment under the FECA and any contribution from work factors is compensable.
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. Your answer must be fully explained to be accepted by OWCP.
Direct Causation: this type of relationship occurs when the injury or factors of employment, through a natural and unbroken sequence, result in the condition claimed.
Aggravation: this type of relationship occurs if a pre-existing condition is worsened, either temporarily or permanently, by the injury or factors of employment.
If you believe the work injury aggravated a pre-existing condition, please indicate whether such aggravation is temporary or permanent and if temporary, when the aggravation ceased or is expected to cease.
Acceleration: an employment-related injury or illness may hasten the development of an underlying condition, and acceleration is said to occur when the ordinary course of the disease does not account for the speed with which a condition develops.
Precipitation: a latent condition which would not have become manifest but for the employment is said to have been precipitated by the injury/factors of the employment.
You may also include any consequential conditions that resulted from the initial work injury or disease; under the FECA, a subsequent injury, whether an aggravation of the original injury or a new and distinct injury, is compensable if it is the direct and natural result of a compensable primary injury.
Disability status
Box 10: Please circle the patient's current disability status: Totally disabled: the claimant is unable to perform any and all work. Partially disabled: the claimant is incapable of performing the job held when injured, but is capable of some work. Not disabled: the claimant is capable of performing the job held when injured.
If Totally Disabled, provide the date disability commenced and the date of anticipated return to full or modified work (the date of anticipated return to regular or modified work).
If Partially Disabled, also, complete Box 11, and provide the date disability commenced and the date of anticipated return to full duty work (the date of anticipated return to regular duty work).
If Not Disabled, indicate any previous dates of disability: Was there any disability in the case? If so, indicate dates of disability: From to.
Extent of physical limitations
Box 11: If you stated the patient was partially disabled in Box 10, please 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, if you would prefer to provide work capacity information separately.
Remarks
Box 12: If you have any additional remarks regarding this patient's work injury, please provide here; if not, leave blank.
Signature of Treating Provider
OMB No. 1240-0046 Expires: 09/30/2026. Box 13: Please sign and date the form. If you are not a physician, a physician must co-sign and date the form as well.
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. If treating provider is not a physician (i.e. nurse, physician's assistant), a co-signature from a physician is required below.
Name of Physician and Tax ID Number
Box 14-17: Please provide the name, address and tax identification number of the physician signing the form: write the Name of Physician and the Tax ID Number.
Physician address and Do you specialize?
Write the Address, ZIP, State and City. 16. Do you specialize? Check Yes or No. 17. If yes, indicate specialty. If the physician is Board-certified in a particular specialty, please indicate such and provide the specific specialty in Box 17.
More rules for Form CA-20
A medical report is required by OWCP before payment of compensation for loss of wages or permanent disability can be made to the employee.
This information is required to obtain or retain a benefit (5 U.S.C. 8101, et seq.).
OWCP requires that medical bills, other than hospital bills, be submitted on the American Medical Association health insurance claim form, HCFA 1500/OWCP-1500.
ECOMP will then provide you with a Tracking Number so that you can verify when OWCP has received the CA-20; for more detailed information about this document submission feature, visit the ECOMP website and click "Help."
Under the FECA, medical evidence must be submitted by a qualified physician.
Nurse practitioners and physician assistants are not considered qualified physicians under the FECA unless the medical report is countersigned by a physician.
A “physician” includes clinical psychologists acting within the scope of their practice.
Also, under the FECA, a “physician” includes chiropractors only if there is a diagnosed spinal subluxation and it is demonstrated by x-ray.
Common questions about Form CA-20
What is the CA20 form used for?
This is the Attending Physician's Report of the U.S. Department of Labor Office of Workers' Compensation Programs.
What is eComp used for?
To expedite the processing of this patient's claim, you can concurrently upload this form directly into their case file using the Employees' Compensation Operations and Management Portal (ECOMP); when you access the website, choose the "Upload Document" option, and you will be asked to provide the patient's case number, last name, date of birth and date of injury to upload a document.
Where do I file it?
Please send the completed form and bill to: Office of Workers' Compensation Programs Division of Federal Employees', Longshore and Harbor Workers' Compensation Federal Employees' Compensation Act (OWCP/DFELHWC-FECA) PO Box 8311 London, KY 40742-8311.
Sources
[1] Form CA-20, Attending Physician's Report, U.S. Department of Labor Office of Workers' Compensation Programs (the Official source link on this page).
