Free Alaska Department of Labor - Alaska


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Date: August 27, 2007
File Format: PDF
State: Alaska
Category: Workers Compensation
Author: bwscmpm
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Page Size: Letter (8 1/2" x 11")
URL

http://www.labor.state.ak.us/wc/forms/wc6126.pdf

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Alaska Department of Labor and Workforce Development Fishermen's Fund PO Box 111149 Juneau, AK 99811-1149

Fishermen's Fund
PHYSICIAN'S REPORT

Toll Free: 1-888-520-2766 Telephone: (907) 465-2766 Fax: (907) 465-5345 Email: FishFund@Alaska.gov www.labor.state.ak.us/wc/fishfund.htm

Before the Alaska Commercial Fishermen's Fund may approve benefit payments, Alaska Regulation 8 AAC 55.020(a)(2) requires that the Fund receive a physician's report of treatment. Provider's bills will not be approved until a physician's report has been received. Record of Examination 1. Patient's Name (Last, First, Middle Initial) 4. Date of first examination

2. Date of Injury

3. Social Security Number

5. Date(s) of Treatment From: Through: 7. Did injury require hospitalization? 8. Date of Admission 9. Date of Discharge Yes No (if no, go to item #11) 11. What treatment did you provide? Provide details or attach chart notes

6. Date of Discharge from Treatment 10. Additional Hospitalization Required? Yes No (if yes, describe in item #25)

12. What is your diagnosis? Provide details or attach chart notes

13. Do you believe the condition found was caused or aggravated by commercial fishing activity? Please explain your answer:

Yes

No

14. Is there any history or evidence of concurrent or pre-existing injury or disease or physical impairment? If yes, please describe

Yes

No

15. Remarks

Signature of attending physician 16. Name of Physician 19. Mailing Address 21. City 22. Signature of Physician State

17. Facility Name

18. Tax ID Number 20. Phone Number ( )

Zip Code

Date

Warning: It is a crime to provide false information for the purpose of defrauding the Alaska Commerical Fishermen's Fund, or any other person. Penalties include fines and/or imprisonment. In addition, the Fund may deny payment of all benefits if false information materially related to this claim was provided by the treating physician.

Form 07-6126 (Rev 08/07)