The Alaska Commercial Fishermen's Fund, a state program administered by the Division of Workers' Compensation, pays benefits for injured commercial fishermen. Before it approves any benefit payment, 8 AAC 55.020(a)(2) requires this physician's report. It covers exam and treatment dates, hospitalization, treatment provided, diagnosis, whether fishing caused or aggravated the condition, and any pre-existing impairment.
The attending physician completes items 1 to 22 and signs, adding facility name and tax ID. The fisherman files the Fund's own claim form (07-6125) separately.
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Fishermen's Fund Physician's Report
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Alaska regulation 8 AAC 55.020(a)(2) requires the Fund to receive a physician's report of treatment before it approves benefit payments. Until Form 07-6126 arrives, provider bills are not approved, so sending it promptly keeps both the fisherman's benefits and the provider's payment moving.
No. The Alaska Commercial Fishermen's Fund is a separate state program for commercial fishermen, administered by the Division of Workers' Compensation. It has its own claim form (07-6125), its own release of information form (07-6133) and this physician's report.
Partly. For treatment provided (item 11) and diagnosis (item 12) the form says to give details or attach chart notes. The physician still answers the causation question, the pre-existing condition question and hospitalization items, and signs the form.