Form 07-6102 - Physician'S Report Template Page 2
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1
2INSTRUCTIONS 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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