Fill and Sign the Was Body Part Injured Before Form

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 PHYSICIAN'S REPORT INITIAL Employee: Sections 1 & 2/Physician: Sections 3 & 4 PROGRESS Physician: Sections 1 & 4 TREATMENT PLAN Employee: Sections 1 & 2/ Physician: Sections 3 & 4 AWCB Case Number: SECTION 1 1. Employee's Name (Last, First, Middle Initial) 2. Insurer Claim Number 3. Date of Injury 4. Address City StateZip Code Telephone 5. Sex Male Female 6. Social Security Number 7. Date of Birth 8. Employer 10. Address City StateZip Code Telephone 9. Insurer 11. Address City Zip Code State Telephone SECTION 2 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 If yes, list name and address: 16. Hospitalized As Inpatient? No Yes Name of Hospital: SECTION 3 17. Your First Treatment Date 18. Describe Complaints: 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 Undetermined Explain: (Explain): SECTION 4 23. Treatment Date(s) Since Last Report 24. Next Treatment Date 25. Estimate Length of Further Treatment Days Weeks Months 26. Medically Stable? No Yes 27. Date of Medical Stability 28. Injury May Permanently Preclude Return to Job at Time of Injury No Yes Undetermined 29. Will Injury Result in Permanent Impairment? No Yes Undetermined 30. Impairment Rating 31. Factors on Which Rating is Based 32. Released for Work No Yes Estimate Length of Disability 1-3 Days 4-7 Days 8-14 Days 15-21 Days 22-28 Days More Weeks Months Regular Work Modified Work (Date): (Date):Give Limitations: 33. If the number of treatments will exceed Board's frequency standards,\ state the objectives, modalities, frequency of treatment, and reasons f\ or frequency of treatments. Continue treatment plan on reverse if necessary. GIVE EMPLOYEE AND EMPLOYER/INSUR\ ER 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 CityState 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, Treatmen\ t Plan, or Progress Report. 2. When making an Initial Report or Treatment Plan Report, ask employe\ e 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 o\ f 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 M\ ORE 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 th\ e 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 n\ ot 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 pu\ blic records subject to public inspection and copying under AS 09.25. Form 07-6102 (Rev 01/2013)