Form 07 6102 PDF Details

Form 07 6102 is an important document for tax purposes. It helps to determine your taxable income, and as a result, your tax liability. This form is used by both individuals and businesses, so it's important to understand how it works. In this blog post, we'll go over the basics of Form 07 6102 and explain how to fill it out correctly. We'll also provide some example calculations so you can see how the form works in action. Let's get started!

QuestionAnswer
Form NameForm 07 6102
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names14-day, 3rd, 6th, Insurer

Form Preview Example

 

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

 

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

1.

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

 

 

 

 

 

2. Insurer Claim Number

 

3.

Date of Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Address

 

 

 

 

 

 

 

5. Sex

 

 

 

6. Social Security Number

 

 

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

 

Telephone

 

 

 

 

 

7.

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?

No

Yes

 

 

 

 

 

 

 

 

 

 

If yes, when and describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

Describe Injury and Tell How It Happened:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

No

Yes

 

 

 

16. Hospitalized As Inpatient?

No

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?

No

 

Yes

 

X-Ray Diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22.

Is Condition Work Related?

No

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?

 

No

Yes

 

 

 

 

 

Injury

No

Yes

Undetermined

 

 

No

Yes

Undetermined

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30. Impairment Rating

 

31. Factors on Which Rating is Based

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32.

Released

No

Estimate Length of Disability

 

1-3 Days

4-7 Days

8-14 Days

 

15-21 Days

22-28 Days

More

 

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)

How to Edit Form 07 6102 Online for Free

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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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