Form 07-6102 - Physician'S Report Template

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PHYSICIAN'S REPORT
AWCB Case Number:
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
1. Employee's Name (Last, First, Middle Initial)
2. Insurer Claim Number
3. Date of Injury
5. Sex
4. Address
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
No
Yes
12. Date Last Worked
13. Was Body Part Injured Before?
If yes, when and describe:
14. Describe Injury and Tell How It Happened:
No
Yes
No
Yes
15. Have You Seen Any Other Doctor for This Injury?
16. Hospitalized As Inpatient?
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?
Injury
No
Yes
No
Yes
Undetermined
No
Yes
Undetermined
30. Impairment Rating 31. Factors on Which Rating is Based
Months
32. Released
No
Estimate Length of Disability
1-3 Days
4-7 Days
8-14 Days
15-21 Days
22-28 Days
More
Weeks
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
38. Physician's Signature
37. Physician's Name and Degree (Print or Type)
39. Report Date
40. Address
City
State
Zip Code
41. Telephone
SEE INSTRUCTIONS ON BACK
Form 07-6102 (Rev 01/2013)

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