FECA Medical Report Forms, Claim for Compensation

File Number:
CA-1305-O-TR
U.S. DEPARTMENT OF LABOR

OMB No: 1240-0046
Expiration Date: 3-31-2021

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
Phone: (202) 513-6860
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Date

Date of Injury:
Employee:
Dear Sir/Madam:
Our records show employee may be continuing under your care for the injury on .
We would appreciate receiving a detailed report on the progress and present status of employee,
including a discussion of the items listed below. If you wish first to reexamine the patient, please so
advise and we will ask the patient to schedule an appointment with you.
1. The date of maximum improvement. If maximum improvement has not been reached,
please state when it may be expected and your recommendations for further medical
management, including the requirement for corrective lenses.
2. Current status of the injured eye. Indicate measurable defects to uncorrected vision,
including central visual acuity, far and near; visual field constriction; ocular motility loss; and
ability to fuse vision without glasses.
3. Present status of the uninjured eye (see above), including sympathetic involvement if
present.
4. Any pathological condition observed in either eye.
5. Your recommendation of the percentage impairment of uncorrected vision on the basis of
your clinical findings and the AMA Guides to the Evaluation of Permanent Impairment (Sixth
Edition).
If the injury has resulted in enucleation, the examination should include a careful study of the socket
of the enucleated eye. Please indicate whether any disfigurement has resulted from the enucleation
and give your recommendations as to the need for prosthesis, plastic surgery, or other treatment.
This information will be used to determine entitlement to benefits under the Federal Employees'
Compensation Act.
If you find it necessary to obtain a consultation with another specialist or to hospitalize the claimant in
order to render a fully rationalized opinion, please contact this office at to obtain further authorization.

If you have a disability and are in need of communication assistance (such as
alternate formats or sign language interpretation), accommodations and/or modifications,
please contact OWCP .
CA-1305 (Rev. 03-18)

File Number:
CA-1305-O-TR
OMB No: 1240-0046
Expiration Date: 3-31-2021

To ensure timely payment, use the enclosed numbered billing Form OWCP-1500/HCFA
1500 and use the authorization number in corresponding with or calling the office about
your bill.
The billing form must contain the provider's tax identification number (Social Security
Number or EIN) in block 25 and the signature in Block 31. The medical report must
accompany the bill to ensure prompt payment. Any bill submitted without a medical
report will be held for its arrival, or returned. Payment will be made approximately 30
days from receipt of these documents.
If the marked form is damaged and cannot be used, or if two forms are required, be sure
to submit the bill on a standard American Medical Association Health Insurance Claim
Form (OWCP-1500/HCFA 1500) with your authorization number clearly marked in the
upper right corner.
Sincerely,

Division of Federal Employees' Compensation
Enclosure(s): OWCP-1500/HCFA 1500

CA-1305 PAGE 2 (Rev. 03-18)

File Number:
CA-1305-O-TR
OMB No: 1240-0046
Expiration Date: 3-31-2021

Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond
to this collection of information unless it displays a currently valid OMB control number.
Public reporting burden for this collection of information is estimated at 20 minutes to
complete the collection of this information, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. The obligation to respond to this
collection is required to obtain or retain a benefit under 5 U.S.C. 8101, et seq. Send
comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the U.S. Department of
Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution
Avenue, NW, Washington, DC 20210, and reference the OMB Control Number 12400046. Note: Please do not return the requested information to the address shown just
above. Rather, send it to the address shown on the letterhead.
Privacy Act Statement
The Privacy Act of 1974 as amended (5 U. S.C. 552a) and the Federal Employees’
Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.), authorizes
collection of this information. The information will be used in cases involving eye injury
to determine the extent of loss of vision in complicated eye injury cases. Completion of
this form is voluntary, however, failure to provide the information may result in the delay
of processing of the claim or payment or benefits, or may result in an unfavorable
decision or reduced levels of benefits. Additional disclosures of this information may be
to: third parties in litigation; employing agencies, various individuals and organizations
providing related medical rehabilitation and other services; insurance plans which may
have paid related bills; labor unions; various law enforcement officials; other federal,
state and local agencies (including the GAO and IRS) as appropriate; data processing
contractors to the Department of Labor; debt collection agencies and credit bureaus.”

CA-1305 PAGE 3 (Rev. 03-18)