Loading
Get Form Ca-16, "authorization For Examination
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Form CA-16, "Authorization For Examination" online
Filling out the Form CA-16 is an essential step in gaining authorization for medical examination or treatment for employees injured during duty. This guide provides clear and user-friendly instructions to help you complete the form with confidence.
Follow the steps to complete the Form CA-16 online.
- Press the ‘Get Form’ button to access the Form CA-16 and open it in your editor of choice.
- In Part A, enter the name and address of the medical facility or physician authorized to provide services in item 1.
- Complete item 2 with the employee's name, including last name, first name, and middle initial.
- Input the date of injury in item 3 using the format month, day, year.
- Provide the occupation of the employee in item 4.
- In item 5, describe the injury or disease related to the claim.
- Check the appropriate box under item 6 regarding the duration of medical care authorization, indicating if it is up to sixty days and the respective conditions.
- In item 8, ensure that the authorizing official's signature is present, indicating their agreement to the payment terms.
- Fill in item 9 with the name and title of the authorizing official, printed clearly.
- Enter the local employing agency telephone number in item 10.
- Provide the date in item 11 in the format month, day, year.
- Complete the address details in item 12 for where the report should be sent.
- In item 13, fill in the name and address of the employee's place of employment.
- Once all sections are completed, review the form for accuracy, save your changes, and decide on further action to download, print, or share your form.
Successfully complete the Form CA-16 online to ensure prompt processing of medical examination authorization.
The validity of the CA-16 form typically lasts for 30 days from the date it is issued. This time frame allows employees to schedule their medical examinations promptly. By adhering to this duration, you can ensure that all examinations are conducted under the proper authorization.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.