Treatment Plan

According to Title 23, Chapter 30, Section 95 (AS 23.30.095) of the Alaska Administrative Code, when an injury requires a course of treatment including continuing and multiple treatments of a similar nature, an additional written report on the treatment plan is required if more frequent outpatient visits are necessary than standard treatment for the nature and degree of the injury and type of treatment. This treatment plan is also required within 14 days after treatment has begun and must include the objectives, modalities, frequency of treatments, and reasons for the frequency of treatments.

Physician’s Reports

Physician’s Reports, per AS 8.45.086, must include:

1. A statement whether the report is the first report, a treatment plan, or a progress report;  
2. The date of service;
3. The employee's name, date of injury, date of birth, and social security number;  
4. The date that the employee last worked;
5. A description of the injury and how it happened;
6. A statement whether the body part was injured before the work injury, and identification of the date and circumstances of the earlier injury, if any;
7. The name and address of any other person providing treatment for the injury;  
8. The name of any hospital where the employee was an inpatient for the injury;  
9. The first treatment date;
10. A description of the employee's subjective complaints;
11. A description of objective findings and an assessment of the employee's condition, including the diagnosis;
12. the diagnostic studies prescribed and their results;
13. A statement whether the provider concluded that the condition is work-related and the basis for the conclusion;
14. A treatment plan, including the expected length and nature of treatment, the objectives, modalities, and frequency of treatment, and the justification for the frequency of treatments if the number of treatments:

1. During the first month exceeds three treatments per week;  
2. During the second and third months exceeds two treatments per week;
3. During the fourth and fifth months exceeds one treatment per week; or  
4. During the sixth through twelfth months exceeds one treatment per month;  

15. Justification of the medical necessity for a name-brand drug product if one is prescribed;
16. If the employee is referred to another service provider, the provider's name and address;
17. A statement whether the employee is released to return to work and any restrictions on the employee's regular duties;
18. An estimate of the length of disability if the employee cannot be released to return to work;
19. The date of medical stability or when medical stability is expected;
20. A statement whether the injury will permanently preclude a return to the job held at the time of injury;
21. A statement whether the injury is expected to result in permanent impairment;
22. the permanent partial impairment rating and the factors supporting the rating if the employee is medically stable;
23. The service provider's name, degree, telephone number, and address;
24. The service provider's signature; and
25. The date of the report.

The Physician’s Report Form is available for download from the Alaska Department of Labor and Workforce Development website.

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