Form 07 6102 – Fill Out and Use This PDF

The 07 6102 form, officially known as the Physician's Report for the Alaska Department of Labor & Workforce Development, is a crucial document in managing and reporting the progress and treatment plan of employees under the Alaska Workers' Compensation Board. This form requires detailed input from both the attending physician and the employee, across various sections that cover everything from personal identification to diagnosis, treatment plans, and assessments of work-related injury impacts. Knowing how to accurately complete this form is essential for ensuring timely and appropriate medical care, as well as facilitating accurate compensation for injured employees. Ensure your form is filled out correctly by clicking the button below.

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Form 07 6102 PDF Details

The Form 07 6102, known as the Physician's Report for the Alaska Department of Labor and Workforce Development, plays a crucial role in managing workers' compensation claims within the state. This document facilitates clear communication between physicians, employees, employers, and insurers, ensuring that all parties are informed about the medical status, treatment plan, and progress of injured workers. It is divided into multiple sections, requiring both the employee and the physician to provide detailed information regarding the injury, diagnosis, and the treatment provided. Specifically, this form captures essential details such as the employee's personal information, the nature and details of the injury, previous injuries to the same body part, initial and ongoing treatment details, and projections about the injured worker's ability to return to work, including any permanent impairments. Additionally, the form includes instructions for both physicians and employees, highlighting the importance of timely and accurate reporting to avoid delays in compensation payments and ensuring that the records kept are not publicly disclosed, respecting the privacy of the injured worker. The comprehensive nature of Form 07 6102 underscores its importance in administering workers' compensation claims, guiding the treatment plan, and facilitating an injured worker's return to employment in Alaska.

Question	Answer
Form Name	Form 07 6102
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	14-day, 3rd, 6th, Insurer

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		PHYSICIAN'S REPORT
	ALASKA DEPARTMENT OF LABOR &	INITIAL Employee: Sections 1 & 2/Physician: Sections 3 & 4
	WORKFORCE DEVELOPMENT	PROGRESS Physician: Sections 1 & 4
	Alaska Workers' Compensation Board	PROGRESS Physician: Sections 1 & 4
	Alaska Workers' Compensation Board
	P.O. Box 115512, Juneau AK 99811-5512	TREATMENT PLAN Employee: Sections 1 & 2/ Physician: Sections 3 & 4

AWCB CASE NUMBER:

SECTION 1

SECTION 2

SECTION 3

SECTION 4

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

2. Insurer Claim Number

Date of Injury

Address

5. Sex

6. Social Security Number

Male

Female

City

State

Zip Code

Telephone

Date of Birth

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?

Yes

If yes, when and describe:

14.

Describe Injury and Tell How It Happened:

15. Have You Seen Any Other Doctor for This Injury?

Yes

16. Hospitalized As Inpatient?

Yes

If yes, list name and address:

Name of Hospital:

18. Describe Complaints:

17.

Your First Treatment Date

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

20.Diagnosis:

21.

X-Rays?

Yes

X-Ray Diagnosis:

22.

Is Condition Work Related?

Yes

Explain:

Undetermined

(Explain):

23. Treatment Date(s) Since Last Report

24. Next Treatment Date

25. Estimate Length of Further Treatment

Days

Weeks

Months

26.

Medically Stable?

27. Date of Medical Stability

28. Injury May Permanently Preclude Return to Job at Time of

29. Will Injury Result in Permanent Impairment?

Yes

Injury

Yes

Undetermined

Yes

Undetermined

30. Impairment Rating

31. Factors on Which Rating is Based

32.

Released

Estimate Length of Disability

1-3 Days

4-7 Days

8-14 Days

15-21 Days

22-28 Days

Weeks

Months

for Work

Yes

Regular Work (Date):

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.

34. Describe Treatment (and/or Attach 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

SEE INSTRUCTIONS ON BACK

Form 07-6102 (Rev 01/2013)

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)

43. Report Date

44. REMARKS (or Treatment Plan continued)

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)

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So as to complete this PDF form, make certain you enter the information you need in each and every blank:

1. Complete the 2010 with a number of major fields. Collect all of the information you need and ensure absolutely nothing is overlooked!

Find out how to fill in physicians report portion 1

2. Once the previous part is completed, it's time to include the essential specifics in N O T C E S, Fully Describe Findings on First, Diagnosis, XRays, Yes, XRay Diagnosis, Is Condition Work Related, Yes, Explain, Undetermined, Explain, Treatment Dates Since Last Report, Next Treatment Date, Estimate Length of Further, and Days in order to move forward to the 3rd stage.

Undetermined, Is Condition Work Related, and Next Treatment Date in physicians report

3. This next segment is considered pretty simple, If Case Referred to Another, Physicians Name and Degree Print, Physicians Signature, IRS ID Number, Report Date, Address, City, State, Zip Code, Telephone, Form Rev, and SEE INSTRUCTIONS ON BACK - every one of these form fields will have to be filled in here.

physicians report completion process shown (part 3)

4. Filling in Employees Name Last First Middle, REMARKS or Treatment Plan, and Report Date is key in this form section - don't forget to don't hurry and be mindful with each and every empty field!

Stage number 4 in completing physicians report

It is possible to get it wrong while filling in the Report Date, consequently you'll want to reread it before you'll finalize the form.

5. The last section to submit this document is critical. You must fill in the necessary blanks, and this includes Medical records in an employees, and Form Rev, before finalizing. Failing to do it might result in an unfinished and possibly nonvalid form!

The best way to fill out physicians report step 5

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Form 07 6102 – Fill Out and Use This PDF

Form 07 6102 PDF Details

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