The 27 Alaska forms that ask for a clinician's input, from Medicaid travel and DME certificates to the workers' comp Physician's Report and ASAA sports exams.
This page lists the 27 Alaska forms that ask for a clinician's input, grouped by program. On workers' comp claims the treating physician files the Physician's Report, Form 07-6102, which covers initial, progress and treatment-plan reports. Alaska Medicaid asks for a Service Authorization Request, the General Prescriber Page of the Certificate of Medical Necessity for DMEPOS, and the Travel Certification of Medical Necessity. DMV uses Form 861 for disability parking and Form 468 for eye, medical and mental fitness to drive.
Send the original 07-6102 to the employer or insurer within 14 days of each treatment; it is not filed with the Board. The Fishermen's Fund won't approve provider bills until it has Form 07-6126. ASAA accepts a Student Health Review/Exam done within the previous 18 months. Form 861 can be certified by a broad list of licensed Alaskan professionals, including PTs, OTs and chiropractors. The medical marijuana physician statement must be an original, not a photocopy. The school meal Medical Statement also comes in Spanish.
07-6102Initial, progress and treatment-plan report from the treating physician on diagnosis, work-relatedness, medical stability, permanent impairment rating and release to regular or modified work.
Physician's report of treatment, diagnosis and causation that the Alaska Commercial Fishermen's Fund requires before approving benefit payments or provider bills for a commercial fisherman's injury.
07-6177Documents the baseline lung, heart and cancer-screening examination a firefighter needs to qualify for the workers' compensation occupational-disease presumption under AS 23.30.121.
Licensed physician certifies that a PERS/TRS retiree must leave Alaska for medical care for a stated number of months, so the retiree keeps the Alaska Cost-of-Living Allowance despite an absence longer than 90 days (up to six months).
Records visual acuity and the examiner's opinion on safe driving and restrictions for applicants who fail the DMV vision screening (vision test waiver).
Collects eye, medical, loss-of-consciousness/seizure and mental health assessments so DMV can decide whether the patient can safely operate a motor vehicle.
Applies for a permanent, temporary or visitor disability parking permit or plates with parking privileges, with a licensed Alaskan professional's certification of the qualifying condition.
Prescriber's certificate of medical necessity supporting a DMEPOS service authorization (items, diagnoses, length of need).
General medication prior authorization request, also used to exceed maximum allowed units, for drugs without a drug-specific form.
General Alaska Medicaid service authorization (prior authorization) request for medical services other than dental, long-term care and behavioral health.
Treating provider certifies medical necessity for Medicaid travel when the member bypasses the closest provider, travels out of state, or needs an adult or multiple escorts.
Requests or updates service authorization for Medicaid home health services with diagnosis and medical justification.
Certifies a health history and physical exam within the prior 18 months for eligibility in ASAA activities.
Health care provider's written release for a student removed for a suspected concussion to begin/complete the return-to-play protocol (Alaska AS 14.30.142).
Physician release allowing a wrestler with a treated skin lesion to compete.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Physician states they personally examined the applicant in a bona fide physician-patient relationship, that the applicant has a debilitating condition under AS 17.37.070, and that the patient might benefit from medical marijuana.
Reports a case of a reportable infectious disease (other than STD/HIV) to the State of Alaska Section of Epidemiology.
Written report of suspected child abuse or neglect to the Office of Children's Services.
Report of harm (abuse, neglect, self-neglect, exploitation, abandonment) to a vulnerable adult made to Adult Protective Services.
Reports elevated heavy metal results or toxic exposures (arsenic, cadmium, cobalt, lead, mercury), including blood lead at or above the CDC reference value.
Reports a case of HIV, gonorrhea, syphilis, chlamydia or other reportable STD, with treatment and partner information.
Reports a firearm injury, a condition reportable to the Section of Epidemiology.
Professional certifies that the applicant is deaf, hard of hearing or has a severe speech disability that creates a barrier to distance communication, for free telecom equipment/tablets.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The treating physician sends the original to the employer or insurer within 14 days of each treatment and gives copies to the employee. It is not filed with the Board. One form covers initial, progress and treatment-plan reports, and a treatment plan is needed only when treatment exceeds the Board's frequency standards under 8 AAC 45.082. The physician completes Sections 3 and 4, including medical stability and the impairment rating.
ASAA accepts a health history and physical exam done within the previous 18 months. A physician, advanced nurse practitioner, physician assistant, doctor of chiropractic or military medical examiner signs the Student Health Review/Exam, and the student returns it to the school activities office. A student removed for a suspected concussion also needs the Healthcare Provider Release before starting the return-to-play protocol under AS 14.30.142.
A licensed Alaskan physician, PA, nurse practitioner, podiatrist, speech-language pathologist, chiropractor, physical therapist or occupational therapist completes Part 2 of Form 861. The form covers permanent, temporary and visitor permits, and plates with parking privileges. Part 2 also asks whether the patient holds a CDL and meets 49 CFR 391.41. The applicant submits it to DMV in person or by mail.
When a member bypasses the closest provider, travels out of state, or needs an adult escort or more than one escort. The treating provider, or an RN under physician delegation, completes Section 3, Medical Certification, and signs the attestation. The certification goes with the online or telephone travel authorization request to the fiscal agent, and it is valid for up to 1 year.