Last updated: 7/8/2016
Medical Summary {07-6103}
Start Your Free Trial $ 13.99What you get:
- Instant access to fillable Microsoft Word or PDF forms.
- Minimize the risk of using outdated forms and eliminate rejected fillings.
- Largest forms database in the USA with more than 80,000 federal, state and agency forms.
- Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
- Trusted by 1,000s of Attorneys and Legal Professionals
Description
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's Name (Last, First, Middle Initial) Employer TO: (List all persons to whom you are mailing this summary. Include addresses.) AWCB Case Number Date of Injury Employee's Social Security Number WORKERS' COMPENSATION MEDICAL SUMMARY 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 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 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 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 Brief Description of Medial Record (option but please identify most important records Proof of Service: I certify that I mailed a copy of this summary to the persons and addresses Name of Person Who Prepared This Summary (Print or Type) listed above: Name of Person Certifying Service (Print or Type) Signature Date Mailed 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 Development Alaska Workers' Compensation Board 3301 Eagle Street, Suite 304 Anchorage, AK 99503 (907) 269-4980 Alaska Department of Labor & Workforce Development Alaska Workers' Compensation Board 675 Seventh Avenue, Station K Fairbanks, AK 99701-4531 (907) 451-2889 American LegalNet, Inc. www.FormsWorkFlow.com Alaska Department of Labor & Workforce Development Alaska Workers' Compensation Board P.O. Box 115512 Juneau, AK 99811-5512 (907) 465-2790 Form 07-6103 (Rev 05/2012)
Related forms
-
Affidavit Of Compensation Rate Less Than $154
Alaska/Workers Comp/ -
Affidavit Of Readiness For Hearing
Alaska/Workers Comp/ -
Application For Certificate Of Self Insurance
Alaska/Workers Comp/ -
Compensation Report
Alaska/Workers Comp/ -
Compromise And Release Agreement Summary
Alaska/Workers Comp/ -
Controversion Notice
Alaska/Workers Comp/ -
Death Benefits Report
Alaska/Workers Comp/ -
Employers Notice Of Insurance
Alaska/Workers Comp/ -
Medical Summary
Alaska/Workers Comp/ -
Notice Of Possible Claim Against The Second Injury Fund
Alaska/Workers Comp/ -
Petition To Join Second Injury Fund And Claim For Reimbursement
Alaska/Workers Comp/ -
Physicians Report
Alaska/Workers Comp/ -
Release Of Counseling Psych Psychiatric Or Alcohol Drug Substance Abuse Treatment Records Or Info
Alaska/Workers Comp/ -
Renewal Certificate Of Self Insurance
Alaska/Workers Comp/ -
Request For Conference
Alaska/Workers Comp/ -
Request For Cross Examination
Alaska/Workers Comp/ -
Subpoena
Alaska/Workers Comp/ -
Second Independent Medical Evaluation (SIME)
Alaska/Workers Comp/ -
Report Of Occupational Injury Or Illness
Alaska/Workers Comp/ -
Waiver Of Reemployment Benefits
Alaska/Workers Comp/ -
Employee Report Of Occupational Injury Or Illness To Employer
Alaska/Workers Comp/ -
Change Of Address
Alaska/Workers Comp/ -
Notice Of Appearance
Alaska/Workers Comp/ -
Notice Of Intent To Rely
Alaska/Workers Comp/ -
Public Records Request
Alaska/Workers Comp/ -
Request For Release Of Information
Alaska/Workers Comp/ -
Affidavit Verifying SIME Records Are Complete
Alaska/Workers Comp/ -
Claim For Workers Compensation Benefits
Alaska/Workers Comp/ -
Release of Medical Information
Alaska/6 Workers Comp/ -
Firefighters Lung And Heart Physical Examination And Cancer Screening
Alaska/6 Workers Comp/ -
Firefighters Medical History And Evaluation
Alaska/6 Workers Comp/ -
Fishermens Fund Claim Form
Alaska/6 Workers Comp/ -
Fishermens Fund Compelling Reasons Questionnaire (Form 07-6124}
Alaska/6 Workers Comp/ -
Fishermens Fund Physicians Report
Alaska/6 Workers Comp/ -
Application To Provide Reemployment Services As A Rehabilitation Specialist
Alaska/6 Workers Comp/ -
Reemployment Eligibility Evaluation Checklist
Alaska/6 Workers Comp/ -
Employer Notice Of 45 Consecutive Days Of Time Loss For Injuries
Alaska/6 Workers Comp/ -
Reemployment Employer Notice Of 90 Consecutive Days Of Time Loss For Injuries
Alaska/6 Workers Comp/ -
Offer Of Alternative Employment
Alaska/6 Workers Comp/ -
Reemployment Benefits Plan Checklist
Alaska/6 Workers Comp/ -
Reemployment Stipulation To Eligibility For Injuries
Alaska/6 Workers Comp/ -
Fishermens Fund Report Of Vessel Site Insurance
Alaska/6 Workers Comp/ -
Guide For Preparing Reemployment Benefits Eligibility Form
Alaska/6 Workers Comp/ -
Petition
Alaska/Workers Comp/ -
Fishermans Fund Request For Release Of Information
Alaska/Workers Comp/ -
Crewman Agreement Regarding Medical Related Transportation Or Other Expenses
Alaska/Workers Comp/ -
Election To Either Receive Reemployment Benefits Or A Job Dislocation Benefit
Alaska/Workers Comp/
Form Preview
Contact Us
Success: Your message was sent.
Thank you!