Form CA-15 Peace Corps Volunteer Authorization for Examination And/

Peace Corps Volunteer Authorization
for Examination And/Or Treatment

U.S. Department of Labor
Office of Workers' Compensation Programs

The following request for information is required under (5 USC 8101 et. seq.). Benefits and/or medical services expenses may
not be paid or may be subject to suspension under this program unless this report is completed and filed as requested.
Information collected will be handled and stored in compliance with the Freedom of Information Act, the Privacy Act of 1974 and
0MB Cir. No. 130. Persons are not required to respond to this collection of information unless it displays a currently valid 0MB
control number. NOTE: THIS FORM IS NOT TO BE REPRODUCED OR DUPLICATED (See Instructions). IF INSTRUCTIONS
ARE SEPARATED FROM THIS FORM, REFER TO FORM INFORMATION https://www.dol.gov/agencies/owcp/FECA

0MB No.: 1240-0059
Expires: 02/28/2026

PART A - AUTHORIZATION
1. Name and Address of the Medical Facility or Physician Authorized to Provide the Medical Service within the meaning of FECA (See
Instructions for definition of a qualified physician):
2. Volunteer's Identification (last, first, middle, SSN)

3. End of Service Date (Coverage Start Date) 4. Date of Injury (mo. day, yr.)

5. Description of Injury or Disease:

6. You are authorized to provide medical care for the Volunteer for a period of up to 120 days from the End of Service Date, subject to the
condition stated in item A, and to the condition indicated in either 1 or 2, item B.
A. Your signature in item 24 of Part B certifies your agreement that all fees for services shall not exceed the maximum allowable fee
established by OWCP and that payment by OWCP will be accepted as payment in full for said services. PLEASE NOTE THIS
AUTHORIZATION DOES NOT INCLUDE PRESCRIPTIONS FOR COMPOUND OR OPIOID MEDICATIONS OR PHYSICIAN
DISPENSED MEDICATION. SEE INSTRUCTIONS FOR ADDITIONAL MEDICAL INFORMATION.
B.

1. Furnish office and/or hospital treatment as medically necessary for the effects of this injury. Any surgery other than emergency
must have prior OWCP approval.
2. There is doubt whether the employee's Volunteer's condition is caused by an injury sustained in the performance of duty, or is
otherwise related to Peace Corps service. You are authorized to examine the Volunteer using indicated non-surgical diagnostic
studies, and promptly advise the undersigned whether you believe the condition is due to the alleged injury or to any
circumstances of the volunteer service. Pending further advice you may provide necessary conservative treatment if you believe
the condition may be related to Peace Corps service.

7. Name and Address of Peace Corps Office

8. Peace Corps Telephone Number (Including Area Code):

Department or Agency: Peace Corps
Bureau or Office: Office of Health Services
Local Address (Including Zip Code)
9. Name and Title of Authorized Official (Type or Print Clearly): (See
Instructions)

10. Send one copy of your report 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

11. I certify that I am the individual authorized by Peace Corps to issue 12. Remarks (See Instructions under Authorized Official):
this form concerning medical treatment. I further certify that the
information provided above is true and accurate to the best of my
knowledge and belief. I realize that any person who knowingly makes
any false statement or misrepresentation to obtain FECA compensation
is subject to civil or administrative remedies as well as criminal
prosecution.
Signature of Authorizing Official/Date (Month, Day/Year)
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. See form instructions for REQUESTS FOR ACCOMMODATIONS OR
AUXILIARY AIDS AND SERVICES.
CA-15 (Rev. XX-XX)

PART B - ATTENDING PHYSICIAN'S REPORT
13. Peace Corps Volunteer's Name (last, first, middle)

14. OWCP File No. (if
available):

15. Date of Initial
Treatment:

16. Date of this
Examination:

17. How did the Peace Corps Volunteer’s injury occur?

18. 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.

19. Medical Diagnosis(es): Please note that “pain” is not a compensable diagnosis; you may however note pain in
box 19 above as a symptom of a specific diagnosis or diagnoses.

21. Please select the patient’s current disability status:

Totally Disabled

Partially Disabled

20. ICD Code(s)

Not Disabled

If Totally Disabled.

Date disability commenced:

Date of anticipated return to full or modified work:

If Partially Disabled.

Date disability commenced:

Date of anticipated return to full duty work Also, complete Box 24.

If Not Disabled.

Was there any disability in the case?

If so, indicate dates of disability: From

to

22. 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

23. Remarks

Signature
24. 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:
Date _____________________
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:

Date ____________________

25. Name of Physician:
Address:

City

State

Zip

26. Do you specialize? 27. If yes, indicate
specialty
Yes
No

PAYMENT/MEDICAL BILLING: This CA-15 guarantees payment to the original treating physician (or any physician to whom the employee was
referred by the original treating physician) for 120 days from the End of Service Date unless OWCP terminates this authority at an earlier date.
Treatment may continue at OWCP expense if the claim is approved. Charges for your services should be presented on the AMA standard
"Health Insurance Claim Form" (HCFA-1500, OWCP-1500, OWCP-04 or the UB-04). Physician services must be itemized by Current
Procedural Terminology Code (CPT) using current CPT-4 coding schema; or, the UB-04 and the coding schemas acceptable on this form.
CA-15 PAGE 2 (Rev. XX-XX)

INSTRUCTIONS FOR AUTHORIZING OFFICIAL FOR COMPLETION OF PART A. PLEASE READ FIRST. The CA-15 is solely used by the
Peace Corps to authorize initial care to an injured Volunteer. To protect against potential fraud and abuse, it is important that this form not be
duplicated or reproduced without express written consent by OWCP to include via electronic means (including Internet posting).
PLEASE ENSURE THESE INSTRUCTIONS ACCOMPANY THE CA-15 FORM.
AUTHORIZING
OFFICIAL

• Authorized personnel may include any Office of Health Services staff whose current position includes duties
related to the FECA program.

SELECTION OF
PHYSICIAN

• A Peace Corps volunteer injured while in the performance of duty has the initial right to select a physician of
his/her choice to provide necessary treatment.
• If a Volunteer elects to be treated by a private physician; a copy of the American Medical Association
Standard Billing Form (AMA) OWCP-1500 should be supplied together with the submitted Form CA-15.
Additionally, medical providers should register with the OWCP Medical Bill Processing Contractor in order to
receive payment. Further information can be found on the DFEC website at
https://www.dol.gov/agencies/owcp/FECA
• If a Volunteer in an emergency situation has to be sent and/or admitted to an Acute Care Facility for
emergency surgery or care, a copy of the OWCP Uniformed Billing Form (UB-04-1450) should be supplied
together with the submitted Form CA-15.
• A physician who is excluded from the FECA program as provided at 20 CFR 10.815-826 may not be
authorized to examine or treat an injured Federal employee, including Peace Corps Volunteers.
• Generally, a roundtrip distance of up to 100 miles from the place of injury, employing agency, or the
Volunteer's home is a reasonable distance to travel for medical care; however, other pertinent factors must
also be considered. For non-emergency medical treatment, if roundtrip travel of more than 100 miles is
contemplated, or air transportation or overnight accommodations will be needed, submit a written request to
OWCP for prior authorization with information describing the circumstances and necessity for such travel
expenses.

PERIOD OF
AUTHORIZATION

• Form CA-15 is valid for up to 120 days from the End of Service date, and may be terminated earlier upon
written notice from OWCP to the provider. It should not be used to authorize a change of physicians after the
initial choice is exercised by the Volunteer.

FEDERAL MEDICAL
FACILITIES

• U.S. Medical Facilities include Army, Navy, Air Force or the VA. Federal health service facilities (health units)
established under 5 USC 7901 are not U.S. medical facilities as used herein (see 20 CFR 10.300).

DEFINITION OF
INJURY

• The term "injury" includes damage to or destruction of medical braces, artificial limbs and other prosthetic
devices. Eyeglasses and hearing aids are included only if the damages were incidental to a personal injury
which required medical services. Simple exposure to a workplace hazard, such as an infectious agent, does
not constitute a work place injury, entitling an employee to medical treatment under FECA.

QUALIFIED
MEDICAL
FACILITY/
PHYSICIAN

• Qualified hospital means any hospital licensed as such under State law which has not been excluded by the
FECA program in accordance with its governing regulations. Except as otherwise provided by regulation, a
qualified hospital shall be deemed to be designated or
approved by OWCP.
• Qualified provider of medical support services or supplies means any person, other than a physician or a
hospital, who provides services, drugs, supplies and appliances for which OWCP makes payment who
possesses any applicable licenses required under State law, and who has not been excluded.
• The term "physician" includes doctors of medicine (MDs), surgeons, podiatrists, dentists, clinical
psychologists, optometrist, chiropractors, and osteopathic practitioners within the scope of their practice as
defined by State law. The reimbursable services of chiropractors under the FECA are limited by statute to
physical examination related laboratory test and X-rays to diagnosis a subluxation of the spine and treatment
consistent of manual manipulation of the spine to correct a subluxation demonstrated by X-ray.
• Qualified physician means any physician who has not been excluded under the provisions of subpart I of this
part. Except as otherwise provided by regulation, a qualified physician shall be deemed to be designated or
approved by OWCP. (See 20 CFR 10.5, WHAT DEFINITIONS APPLY TO REGULATIONS IN THIS
SUBCHAPTER).
• Part A shall be completed in full by the authorizing official. The authorization is not valid unless the name
and address of the physician or hospital is entered I item 1 and the signature of the authorizing official
appears in item 9. Check B1 or B2 in item 6, whichever is appropriate.

FORM COMPLETION

• Send the completed form to the OWCP address shown in item 10. Send original and one copy of Form
CA-15 to the medical officer or physician. If issued for illness or disease, a copy must also be sent to OWCP.

ADDITIONAL INFORMATION

• See 20 CFR 10.730

REQUESTS FOR
ACCOMMODATIONS OR
AUXILIARY AIDS AND SERVICES

• If you have a disability, federal law gives you the right to receive help from the OWCP in the form of
communication assistance, accommodation(s) and/or modification(s) to aid you in the claims process. For
example, we will provide you with copies of documents in alternate formats, communication services such as
sign language interpretation, or other kinds of adjustments or changes to accommodate your disability.
Please contact our office or your OWCP claims examiner to ask about this assistance.

CA-15 PAGE 3 (Rev. XX-XX)

INSTRUCTIONS FOR AUTHORIZED PHYSICIAN/MEDICAL FACILITY FOR COMPLETION OF PART B
YOUR AUTHORIZATION

• Please read Part A of Form CA-15. You are authorized to examine and provide treatment for the injury or
disease described in Item 5, for a period of not more than 120 days from the End of Service date, subject to
the conditions in Item 6. A physician who is debarred from the FECA program as provided at 20 CFR
10.815-826 may not be authorized to examine or treat an injured Federal employee, including Peace Corps
Volunteers. Authorization may be terminated earlier upon written notice from OWCP. For extension of the
authorization to treat beyond the 120 day period, forward your request to the address shown in Part A.
Item 10.
• This form covers office visits and consultations, laboratory work, hospital services (including inpatient), xrays, MRls, CT scans, physical therapy, emergency services (including surgery) and chiropractic services.
Chiropractic services are limited to charges for physical examinations and x-rays to diagnose a subluxation
of the spine and treatment consisting of manual manipulation of the spine to correct a subluxation
demonstrated by x-ray.
• This form does not cover elective and non-emergency surgery, home exercise equipment, whirlpools,
mattresses, spa/gym membership and work hardening programs. ALSO, PLEASE NOTE THIS
AUTHORIZATION DOES NOT INCLUDE PRESCRIPTIONS FOR COMPOUND OR OPIOID MEDICATION
OR PHYSICIAN DISPENSED MEDICATIONS BILLED WITH HCPCS CODES J3490, J3590, J7999, J8499,
J8999 OR J9999.

USE OF CONSULTANTS
AND HOSPITALS

• You may utilize consultants, laboratories and local hospitals, if needed. A private room may be authorized
only if the diagnosed condition is medically necessary as determined by the treating physician and concurred
by the OWCP District Medical Advisor. Ancillary treatment may be provided to a hospitalized Volunteer as
necessary.

REPORTS

• After examination, complete items 13 through 23, of Part B, and send your report, together with any
additional narrative or explanatory material, to the address listed in Part A, item 10. Delay in submitting
medical reports may delay payment of benefits.

RELEASE OF
RECORDS

• Injury reports are the official records of OWCP. They shall not be released to anyone nor may any other use
be made of them without the approval of OWCP.

BILLING FOR
SERVICES

• All medical providers must be enrolled with our Medical Bill Processing Contractor in order to receive
authorization and payment. Additional information can be found on our website at
https://www.dol.gov/agencies/owcp/FECA
• If a Volunteer elects to be treated by a private physician, a copy of the American Medical Association
Standard Billing Form (AMA) OWCP-1500 should be supplied together with the submitted Form CA-15.
• OWCP requires that when services are provided by a private physician, charges be itemized using the AMA
standard Health Insurance Claim Form, HCFA-1500/OWCP-1500. The form should contain appropriate
International Classification of Disease (ICD) coding schemas in Block-21, and related correctly to the
Diagnosis Pointers referenced in Block 24E. The form should also identify services rendered using the
Current Procedural Terminology (CPT-4), and HealthCare Common Procedure Codes (HCPC) schemas.
• OWCP requires that when services are performed in an emergency situation, and in an Acute Care Facility
for emergency surgery or care, a copy of the OWCP Uniformed Billing Form (UB-04-1450), should be
supplied together with the submitted Form CA-15. The form should contain the appropriate International
Classification of Diseases (ICD) coding schemas in Blocks 66-70, and reference any surgical procedures
performed in the facility in Blocks 74a-74e using the International Classification of Disease (ICD) Surgical
Procedure Codes. The UB-04 should be itemized in Block #42 in a summarization listing all ancillary services
performed during the stay, and each service; (radiology, Labs, pharmacy, supplies, etc.,) should be
referenced using Revenue Center Codes (RCC), Payment for chiropractic services is limited to charges for
physical examinations, related laboratory tests, and X-rays to diagnose a subluxation of the spine; and
treatment consisting of manual manipulation of the spine to correct a subluxation demonstrated by X-ray.

TAX IDENTIFICATION
NUMBER

• The Provider/Facility Tax Identification Number (TIN) is an important identifier in the OWCP system. To
ensure accurate processing and to reduce inaccuracy of payment, the provider billing on an OWCP-1500
billing form should reference the TIN (Employer Identification Number or SSN in Block #25), and indicate this
identifier on all submitted reports and billings submitted consistently. The Tax Identification Number for
Facilities billing on the UB-04 Billing form, should reference their Federal Tax Identification number in
Block #5.

ADDITIONAL
INFORMATION

• Refer to Information for Medical Providers at https://www.dol.gov/agencies/owcp/FECA

REQUESTS FOR
ACCOMMODATIONS OR
AUXILIARY AIDS AND
SERVICES

• If you have a disability, federal law gives you the right to receive help from the OWCP in the form of
communication assistance, accommodation(s) and/or modification(s) to aid you in the claims process. For
example, we will provide you with copies of documents in alternate formats, communication services such as
sign language interpretation, or other kinds of adjustments or changes to accommodate your disability.
Please contact our office or your OWCP claims examiner to ask about this assistance.

CA-15 PAGE 4 (Rev. XX-XX)

PUBLIC BURDEN STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection
displays a valid 0MB control number. Public reporting burden for this collection of information is estimated to average fifteen minutes per
response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing
the collection of information. The obligation to respond to this collection is voluntary (5 U.S.C. 8101 et seq.) to obtain or retain a benefit. Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to
the Office of Workers' Compensation Programs, U.S. Department of Labor, Room S3229, 200 Constitution Avenue, N.W., Washington, D.C.
20210, and reference the 0MB Control Number 1240-0059. Note: Do not submit the completed claim form to this address.
PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees'
Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation
Programs of the U. S .Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2)
Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be
verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the
claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to
consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies, other
government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services.
(5) Information may be disclosed to physicians and other healthcare providers for use in providing treatment or medical/vocational rehabilitation,
making evaluation for the Office, and for other purposes related tot he medical management of the claim. the claim. (6) Information may be
given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to
determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to
pursue salary/ administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7) Disclosure
of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN, and other
information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal government, and
for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the processing of the claim or the
payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the processing and
adjudication of the claim you filed under the FECA.

CA-15 PAGE 5 (Rev. XX-XX)