Free Alaska Department of Labor & Workforce Development - Workers' Compensation Division - Alaska


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State: Alaska
Category: Workers Compensation
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http://www.labor.state.ak.us/wc/forms/wc6103.pdf

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WORKERS' COMPENSATION MEDICAL SUMMARY
This form must accompany Workers' Compensation Claims and Petitions (See 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 the Alaska Workers' Compensation Board (addresses listed below).
Employee Employer TO: (List all persons to whom you are mailing this summary. Include addresses.) AWCB Case No. Injury Date Employee's Social Security Number.

Please mark an "X" here if you have no medical records in your possession of this date.
List medical records in chronological order 1. Report date Doctor/Provider 2. Report date 3. Report date 4. Report date 5. Report date 6. Report date 7. Report date 8. Report date 9. Report date 10. Report date 11. Report date 12. Report date 13. Report date 14. Report date 15. Report date 16. Report date 17. Report date 18. Report date Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Doctor/Provider Brief Description of medical record (optional but please identify most important records). Report Type Report Type Report Type Report Type Report Type Report Type Report Type Report Type Report Type Report Type Report Type Report Type Report Type Report Type Report Type Report Type Report Type Report Type

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: Form 07-6103 (Rev.11/2004) Alaska Department of Labor & Workforce Development Alaska Workers' Compensation Board P.O. Box 25512 Juneau, AK 99802-5512 (907) 465-2790

Name of person who prepared this summary (Print or type) REPORT TYPE CODE: Chart Notes = C, Discharge Summary = D, Hospital Records = H, Initial Report = I, Narrative Report = N, Operative Report = O, Physical Examination & History = E, Progress Report = P, X-Ray Report = X, Miscellaneous = M, Second Independent Medical Evaluation = SIME, Employer Independent Medical Evaluation = EIME

Alaska Department of Labor & Workforce Developm Alaska Department of Labor & Workforce Development Alaska Workers' Compensation Board P.O. Box 107019 Anchorage, AK 99510-7019 (907) 269-4980 Alaska Workers' Compensation Board 675 Seventh Avenue, Station H2 Fairbanks, AK 99701-4593 (907) 451-2889