M & R Therapy Center

(813) 877-6900

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CA-1– Notice of Traumatic Injury/ Pay & Compensation

CA-2– Notice of Occupational Disease

CA-2a– Notice of Recurrence

CA-6– Official Superior’s Report of Employee’s Death

CA-7– Claim for Compensation

CA-7a– Time Analysis Form

CA-7b– Leave Buy Back Worksheet

CA-10– What a Federal Employee should do when Injured at work

CA-12– Claim for Continuance of Compensation

CA-17– Duty Status Report

CA-20– Attending Physician’s Report

CA-35– Evidence Required in Support of a claim for Occupational Diseases

CA-40- Designation of a Recipient of the Federal Employees’ Compensation Act Death Gratuity Payment under 5 U.S.C. § 8102a

CA-41- Claim for Survivor Benefits Under the Federal Employees’ Compensation Act Section 8102a Death Gratuity

CA-42- Official Notice of Employees’ Death for Purposes of FECA Section 8102a Death Gratuity

CA-278– Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

CA-721– Notice of Law Enforcement Officer’s Injury Or Occupational Disease

CA-722- Notice of Law Enforcement Officer’s Death

CA-1031– Letter to Dependants to Verify Claimant Support

CA-1074– Letter to Parents in Death Claim Development

CA-1108– Statement of Recovery Letter with Long Form

CA-1122-Statement of Recovery Letter with Short Form

CA-2231– Claim for Reimbursement Assisted Reemployment

OWCP-5a– Work Capacity Evaluation Psychiatric/Psychological Conditions

OWCP-5b– Work Capacity Evaluation Cardiovascular/Pulmonary Conditions

OWCP-5c– Work Capacity Evaluation for Musculoskeletal Conditons

OWCP-16- Rehabilitation Plan And Award

OWCP-17– Rehabilitation Maintenance Certificate

OWCP-20– Overpayment Recovery Questionnaire

OWCP-44- Rehabilitation Action Report

OWCP-04– Uniform Billing Form

OWCP-915– Claim For Medical Reimbursement

OWCP-957– Medical Travel Refund Request

OWCP-1168– Provider Enrollment form

OWCP-1500– Health Insurance Claim Form

SF1199A– Direct Deposit Sign-Up Form