Free WC6102 - Alaska

Alaska Department of Labor Alaska Workers' Compensation Board P.O. Box 25512, Juneau, Alaska 99802-5512

r INITIAL Employee: Sections 1 & 2/Physician: Sections 3 & 4 r PROGRESS Physician: Sections 1 & 4 r TREATMENT PLAN Employee: Sections 1 & 2/Physician: Sections 3 & 4
2. Insurer Claim Number

PHYSICIAN'S REPORT

AWCB Case Number

1. Employee's Name (Last, First, Middle Initial)

3. Injury Date

4. Address

5. Sex r Male r Female

6. Social Security Number

SECTION 1

City

State

Zip Code

Telephone

7. Birthdate

8. Employer

9. Insurer

10. Address

11. Address

City

State

Zip Code

Telephone

City

State

Zip Code

Telephone

12. Date Last Worked

13. Was Body Part Injured Before? r No r Yes If yes, when and describe:

SECTION 2

14. Describe Injury and Tell How it Happened:

15. Have You Seen any Other Doctor for this Injury? r No r Yes If yes, list name and address: 18. Describe Complaints:

16. Hospitalized as Inpatient? r No Name of Hospital:

r Yes

17. YOUR First Treatment Date:

19. Fully Describe Findings on First Examination (Specify Right or Left):

SECTION 3

20. Diagnosis

21. X-Rays? r No r Yes X-Ray Diagnosis: r No r Yes Explain:

22. Is Condition Work Related? r Undetermined (Explain):

23. Treatment Date(s) Since Last Report:

24. Next Treatment Date:

25. Estimate Length of Further Treatment Days Weeks r Yes Months r Undetermined

26. Medically Stable? r No r Yes

27. Date of Medical Stability

28. Injury May Permanently PrecludeReturn toJob at Time of Injury r No r Yes r Undetermined 31. Factors on Which Rating is Based:

29. Will Injury Result in Permanent Impairment? r No

30. Impairment Rating:

32. Released for Work

r No r Yes

Estimate Length of Disability: r 1-3 Days r 4-7 Days r Regular Work (date):

r 8-14 Days r 15-21 Days r 22-28 Days r More: _____ Weeks Give Limitations:

_____ Months

r Modified Work (date):

SECTION 4

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.

34. Describe Treatment (and/or Attach Chart Notes):

35. If Case Referred to Another Physician, State Name and Address:

36. IRS I.D. Number

37. Physician`s Name and Degree (Print or Type)

38. Physician's Signature

39. Report Date

40. Address

City

State

Zip Code

41. Telephone

Form 07-6102 (Rev. 8/95)

SEE INSTRUCTIONS ON BACK

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INSTRUCTIONS TO PHYSICIANS: 1. 2. 3. 4. Clearly mark on reverse whether you are making an Initial, Treatment Plan, or Progress Report. When making an Initial Report or Treatment Plan Report, ask employee to complete Sections 1 and 2. You should complete Sections 3 and 4. 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. A Treatment Plan IS REQUIRED ONLY if you treat the injured worker MORE OFTEN than provided in the following chart: 1st MONTH 3 treatments per week 5. 2nd & 3rd MONTHS 2 treatments per week 4th & 5th MONTHS 1 treatment per week 6th THRU 12th MONTH 1 treatment per month

Within 14 days after each treatment, send the ORIGINAL report to the Alaska Workers' Compensation Board, and a copy to the employer/insurer. 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. Send your billing only to the employer/insurer; the Board does not pay medical expenses. If you need more space than that provided on the front of the form, use the space below. You may make copies of this form. The Board will provide supplies of this form on request. Late or incomplete reporting may delay the employee's compensation payments. The employer/insurer may not be required to pay your treatment charges if reports are not submitted timely.

6. 7. 8. 9.

INSTRUCTIONS TO EMPLOYEE: 1. 2. Complete Sections 1 and 2 of the Initial Report. 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).
43. Report Date

42. Employee's Name (Last, First, Middle Initial)

44. REMARKS (or Treatment Plan continuation)

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. 8/95)

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