Fill and Sign the Lhwca Procedure Manual Division of Longshore and Harbor Form

WORKERS' COMPENSATION MEDICAL SUMMARY This form must accompany Workers' Compensation Claims and Petitions (Se\ e 8AAC 45.052). 1. A copy of the Summary (and any attachments) MUST be served on the \ adjuster or attorney of record. 2. Send the original of the Summary and copies of the attachments to th\ e Alaska Workers' Compensation Board (addresses listed below). Employee's Name (Last, First, Middle Initial) AWCB Case Number Date of Injury Employer Employee's Social Security Number TO: (List all persons to whom you are mailing this summary. Include add\ resses.) Please mark an "X" here if you have no medical records in your possessio\ n of this date. List Medical Records in Chronological Order Brief Description of Medial Record (option but please identify most imp\ ortant records 1. Report Date Doctor/Provider Report Type 2. Report Date Doctor/Provider Report Type 3. Report Date Doctor/Provider Report Type 4. Report Date Doctor/Provider Report Type 5. Report Date Doctor/Provider Report Type 6. Report Date Doctor/Provider Report Type 7. Report Date Doctor/Provider Report Type 8. Report Date Doctor/Provider Report Type 9. Report Date Doctor/Provider Report Type 10. Report Date Doctor/Provider Report Type 11. Report Date Doctor/Provider Report Type 12. Report Date Doctor/Provider Report Type 13. Report Date Doctor/Provider Report Type 14. Report Date Doctor/Provider Report Type Alaska Department of Labor & Workforce Development Alaska Department of Labor & Workforce Development Alaska Department of Labor & Workforce Development Alaska Workers' Compensation Board Alaska Workers' Compensation Board Alaska Workers' Compensation Board P.O. Box 115512 3301 Eagle Street, Suite 304 675 Seventh Avenue, Station K Juneau, AK 99811-5512 Anchorage, AK 99503 Fairbanks, AK 99701-4531 (907) 465-2790 (907) 269-4980 (907) 451-2889 Form 07-6103 (Rev 05/2012) Proof of Service: I certify that I mailed a copy of this summary to the \ persons and addresses listed above: Name of Person Certifying Service (Print or Type) Signature Date Mailed Name of Person Who Prepared This Summary (Print or Type) REPORT TYPE CODE: Chart Notes =C, Discharge Summary = D, Hospital Record\ s =H, Initial Report = I, Narrative Report =N, Operative Report = O, Physical \ Examination & History = E, Progress Report = P, X-Ray Report = X, Miscellaneous = M, Second In\ dependent Medical Evaluation = SIME, Employer Independent Medical Evaluation = EIM\ E 15. Report Date Doctor/Provider Report Type