PHYSICIAN'S REPORT ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 1. Employee's Name (Last, First, Middle Initial) 4. Address INITIAL Employee: Sections 1 & 2/Physician: Sections 3 & 4 PROGRESS Physician: Sections 1 & 4 TREATMENT PLAN Employee: Sections 1 & 2/ Physician: Sections 3 & 4 2. Insurer Claim Number 5. Sex Male Female State Zip Code Telephone 9. Insurer 11. Address State Zip Code Telephone City No Yes State AWCB Case Number: 3. Date of Injury 6. Social Security Number 7. Date of Birth SECTION 1 City 8. Employer 10. Address City 12. Date Last Worked Zip Code Telephone SECTION 2 13. Was Body Part Injured Before? If yes, when and describe: 14. Describe Injury and Tell How It Happened: 15. Have You Seen Any Other Doctor for This Injury? If yes, list name and address: 17. Your First Treatment Date No Yes 16. Hospitalized As Inpatient? Name of Hospital: No Yes 18. Describe Complaints: SECTION 3 19. Fully Describe Findings on First Examination (Specify Right or Left): 20. Diagnosis: 21. X-Rays? No Yes No X-Ray Diagnosis: Yes Explain: 22. Is Condition Work Related? Undetermined (Explain): 23. Treatment Date(s) Since Last Report 26. Medically Stable? No Yes 27. Date of Medical Stability 24. Next Treatment Date 25. Estimate Length of Further Treatment Days Weeks Months 28. Injury May Permanently Preclude Return to Job at Time of Injury No Yes Undetermined 29. Will Injury Result in Permanent Impairment? No Yes Undetermined 30. Impairment Rating 31. Factors on Which Rating is Based 32. Released for Work No Estimate Length of Disability Yes Regular Work (Date): 1-3 Days 4-7 Days 8-14 Days 15-21 Days 22-28 Days More Weeks Months Modified Work (Date): Give Limitations: 33. If the number of treatments will exceed Board's frequency standards, state the objectives, modalities, frequency of treatment, and reasons for frequency of treatments. Continue treatment plan on reverse if necessary. GIVE EMPLOYEE AND EMPLOYER/INSURER A COPY OF THIS REPORT. SECTION 4 34. Describe Treatment (and/or Attach Notes) 35. If Case Referred to Another Physician, State Name and Address: 37. Physician's Name and Degree (Print or Type) 40. Address 38. Physician's Signature City State Zip Code 36. IRS I.D. Number 39. Report Date 41. Telephone SEE INSTRUCTIONS ON BACK Form 07-6102 (Rev 01/2013) American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS TO PHYSICIANS: 1. Clearly mark on reverse whether you are making an Initial, Treatment Plan, or Progress Report. 2. When making an Initial Report or Treatment Plan Report, ask employee to complete Sections 1 and 2. You should complete Sections 3 and 4. 3. When making a Progress Report, complete Items 1, 3, 6, 7, 8 and 9 of Section 1 (you may complete additional items for your own convenience) and Section 4. 4. A Treatment Plan IS REQUIRED ONLY if you treat the injured worker MORE OFTEN than provided in the following chart: 1st MONTH 2nd & 3rd MONTHS 4th & 5th MONTHS 6th THRU 12th MONTH 3 treatments per week 2 treatments per week 1 treatment per week 1 treatment per month 5. Within 14 days after each treatment, send the ORIGINAL report to the Employer. If you treat the employee more frequently than once every 14 days, you may report all treatments during a 14-day period on one form. 6. Send your billing only to the employer/insurer; the Board does not pay medical expenses. 7. If you need more space than that provided on the front of the form, use the space below. 8. You may make copies of this form. 9. Late or incomplete reporting may delay the employee's compensation payments. The employer/insurer may not be required to pay your treatment if reports are not submitted timely. INSTRUCTIONS TO EMPLOYEE: 1. Complete Sections 1 and 2 of the Initial Report. 2. The report is NOT a substitute for your written notice of injury to your employer and the Alaska Workers' Compensation Board. If you have not already done so, immediately contact your employer and complete Items 1 through 17 of the Report of Occupational Injury or Illness (Form 07-6101). 42. Employee's Name (Last, First, Middle Initial) 44. REMARKS (or Treatment Plan continued) 43. Report Date Medical records in an employee's file maintained by the board are not public records subject to public inspection and copying under AS 09.25. Form 07-6102 (Rev 01/2013) American LegalNet, Inc. www.FormsWorkFlow.com