Health Care Provider Report

Download a blank fillable Health Care Provider Report in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Health Care Provider Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Reset
Minnesota Department of Labor and Industry
Health Care Provider Report
Workers’ Compensation Division
See instructions on next page
H C 0 1
(Return completed form to requester)
Print in Ink or type
DO NOT USE THIS SPACE
Enter dates in MM/DD/YYYY format
WID number or SSN
Date of injury
Employee
Employer
Insurer/self-insurer/TPA
Insurer claim number
Insurer address
City
State
ZIP code
Items ___________
MMI (#9)
PPD (#10)
Requester must specify all items to be completed by health care provider:
Health care provider to complete items requested above.
1.
Date of first examination for this injury by this office:
2.
Diagnosis (include all ICD-10-CM codes):
3.
History of injury or disease given by employee:
4.
In your opinion (as substantiated by the history and physical examination) was the injury or disease caused, aggravated or
accelerated by the employee’s alleged employment activity or environment?
No
Yes
5.
Is there evidence of pre-existing or other conditions that affect this disability?
No
Yes
If yes, describe:
6.
Is further treatment of this injury or referral to another health care provider planned?
No
Yes
If yes, describe:
7.
Has surgery been performed?
No
Yes
If yes, date of surgery: ____________________ If yes, describe:
Attach the most recent report of work ability. Date of report: ____________________
8.
9.
Has the employee reached maximum medical improvement (MMI)?
No
Yes Date reached: __________________
(If yes, complete item 10.) (See definition under instructions to the health care provider.)
10. Has the employee sustained any permanent partial disability (PPD) from the injury?
No
Yes
Too early to determine
The permanent partial disability is _______________ % of the whole body. This rating is based on Minnesota Rules:
5223.
%
5223.
%
5223.
%
5223.
%
Health care provider name
Signature
Degree
Address
License/registration number
State
City
State
ZIP code
Phone (include area code)
Date signed
MN HC01 (9/15)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2