Online FECA Intake

  • Online FECA Intake

  • Filling out this form should only take 10-15 minutes.  It is secured, encrypted and HIPAA compliant.  Please provide as much information as you can so that we can best serve you.

     

    Someone from our office should be in touch with you in 1-2 business days.  Alternatively, you can give our office a call to follow up on your submission.

    Thank you - Aumiller Lomax

  • Brief Biographical Information

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  • Date of Birth
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  • Do you have a spouse and/or dependents?

  • Brief Claim Information

  • Date of Injury*
     - -
  • Type of Injury*
  • Is the claim accepted or denied by the OWCP/DOL?*
  • What is the date of the most recent decision from the OWCP/DOL in your case?
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  • Are you presently receiving wage compensation from the OWCP?
  • To the best of your knowledge, have you received all appropriate wage compensation from the OWCP?
  • To the best of your knowledge, have all your medical bills been paid?
  • Did you ever receive a schedule award (permanent injury award) in this case?

  • Brief Employment Information

  • Employment Status

  • Work Status and Income/Benefit Information

  • Are you presently working in any capacity?*
  • Are you presently working full time or part time?*
  • Are you presently working in a full duty or modified duty capacity?*
  • Has your physician given you an estimated return to work date?
  • Are you receiving income or benefits from any of the following sources? (select all that apply):*

  • Medical Treatment / Status

  • In relation to this claim, I am currently treating with the following types of medical providers (select all that apply):

  • I have received the following diagnostic tests (select all that apply):

  • Did you have any surgery in relation to this claim?
  • Does your doctor believe it is likely that you will need surgery?
  • Do you presently have a nurse case manager assigned to your case?
  • Have you been released from medical care by your primary treating physician?

  • The Big Questions

  • Reload
  • Should be Empty: