Below we have listed Federal Workers Compensation Forms to help Flores Medical Center patients in their cases. Each form will give you several options such as download or print.
Federal Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation
Notice of Occupational Disease and Claim for Compensation
Notice of Recurrence
Claim for Compensation by Surviving Spouse and/or Children
Claim for Compensation by Parents, Brothers, Sisiters, GrandParents, or GrandChildren
Official Supervisor's Report of Employee's Death
Claim for Compensation
Time Analysis Form, used for claiming compensation, including repurchase of paid leave
Leave Buy Back (LBB) Worksheet/Certification and Election
What A Federal Employee Should Do When Injured At Work
Claim For Continuance of Compensation Under the Federal Employees' Compensation Act
Duty Status Report
Attending Physician's Report
Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs
This form is only available to registered medical providers by logging into the OWCP Web Bill Portal. To submit the form, providers must click on the 'Provider' Link to the right of the FECA oval located at the top left of the home page, login with their user ID and password, and then click on the 'LMN Documents' link located in the left menu bar. For providers not yet registered, after clicking the 'Provider' link, click the 'Web Registration' link located in the left menu bar to register for web access. For providers not yet enrolled, click on 'Forms & Links' in the horizontal menu at the top of the home page to download the Provider Enrollment form and instructions.
Authorization Request Form and Certification/Letter of Medical Necessity for Opioid Medications
This form is only available to registered medical providers by logging into the OWCP Web Bill Portal. To submit the form, providers must click on the 'Provider' Link to the right of the FECA oval located at the top left of the home page, login with their user ID and password, and then click on the 'LMN Documents' link located in the left menu bar. For providers not yet registered, after clicking the 'Provider' link, click the 'Web Registration' link located in the left menu bar to register for web access. For providers not yet enrolled, click on 'Forms & Links' in the horizontal menu at the top of the home page to download the Provider Enrollment form and instructions.
Evidence Required in Support of a Claim for Occupational Disease
Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment under 5 U.S.C. § 8102a
Claim for Survivor Benefits Under the Federal Employees’ Compensation Act Section 8102a Death Gratuity
Official Notice of Employees’ Death for Purposes of FECA Section 8102a Death Gratuity
Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act
Notice of Law Enforcement Officer's Injury Or Occupational Disease
Notice of Law Enforcement Officer's Death
Letter to Dependants to Verify Claimant Support
Letter to Parents in Death Claim Development
Statement of Recovery Letter with Long Form
Statement of Recovery Letter with Short Form
Claim for Reimbursement Assisted Reemployment
Work Capacity Evaluation Psychiatric/Psychological Conditions
Work Capacity Evaluation Cardiovascular/Pulmonary Conditions
Work Capacity Evaluation for Musculoskeletal Conditions
Rehabilitation Plan And Award
Rehabilitation Maintenance Certificate
Overpayment Recovery Questionnaire
Rehabilitation Action Report
Uniform Billing Form
Claim For Medical Reimbursement
Form OWCP-915 replaces CA-915
Medical Travel Refund Request
Provider Enrollment form
Direct Deposit Sign-Up Form
