Minnesota Department of Labor and Industry Orange bar
Minnesota Department of Labor and Industry Powered by google

Workers' compensation -- Forms



Health Care Provider Report

Who is responsible for completing the form?

  • It is the health care provider's responsibility to complete the form.

    • In lieu of completing the Health Care Provider Report form, the health care provider may respond in a narrative report that contains the same information requested on the form.

    • It is the employer, insurer or commissioner's responsibility to complete the identifying information on the top of the form before sending it to the health care provider.

Why is this form needed?

  • The purpose of this form is to provide the employer, insurer or commissioner with medical information about the employee's work-related injury.

What, specifically, is this form used for?

  • To determine if the employee has reached maximum medical improvement

  • To determine if the employee has a preliminary or final permanent partial disability rating

  • To assist the insurer to manage and monitor medical treatment for a work-related injury

  • To allow the commissioner to keep informed of the nature and extent of all compensable injuries

  • To comply with statutes and rules:

    • Minnesota Statutes 176.101, subd. 1 (j)

    • Minnesota Statutes 176.231, subd. 3, 5, 6 and 7

    • Minnesota Statutes 176.251

    • Minnesota Rules part 5221.0410, subd. 2, 3, 4, 5 and 6

When is this form completed?

  • The health care provider must complete the form within 10 days of receipt of a request for completion of the form from an employer, an insurer or the commissioner.

Where is this form sent?

  • The form is sent by an employer, an insurer or the commissioner to a health care provider. The health care provider returns this form to the requester.

  • The completed form is sent by the self-insured employer, insurer or third-party administrator to the Department of Labor and Industry when the employee has reached maximum medical improvement.

  • The completed form is sent by the self-insured employer, insurer or third-party administrator to the Department of Labor and Industry when there is a preliminary or final permanent partial disability rating.

Links

DLI home page | Directions and maps | News and media | Website disclaimer