Medical Summary {07-6103}

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)