Fillable Health Care Provider Report (Page 2 of 2) in pdf

Notice to employee: Service of this report of maximum medical improvement (see definition below) may affect your

temporary total disability wage-loss benefits. If the insurer proposes to stop your benefits, they must send you a notice of

intention to discontinue benefits. If you have any questions about this form, call your claim representative or call the

Department of Labor and Industry at (651) 284-5032 or 1-800-342-5354.

Instructions to the requester and health care provider

The employer, insurer or commissioner may request required medical information on the Health Care Provider Report form.

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The requester must complete the general information identifying the employee, employer and insurer.

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The requester must specify all items to be answered by the health care provider.

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The requester must send a copy of this form to the employee at the same time it is sent to the health care provider.

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If an injury is required to be reported to the Department of Labor and Industry, the self-insured employer or insurer must file

reports with the department (Minnesota Statutes § 176.231, subd. 1, and Minnesota Rules 5221.0410, subps. 5 and 8).

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The self-insured employer or insurer must serve the report of maximum medical improvement (MMI) on the employee

(Minn. Stat. § 176.101, subd. 1(j), and Minn. Rules 5221.0410, subp. 3).

The health care provider must provide the requested information on this form or in a narrative report within 10 calendar days of the

receipt of a request (Minn. Rules 5221.0410, subps. 3, 4 and 6).

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Item 6: Indicate if further treatment or referral is planned. Describe the treatment plan, for example: continue medication,

refer to physical therapy, refer to a specialist, perform surgery.

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Item 7: Indicate if surgery has been performed. If yes, fill in the date performed and describe the procedure.

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Item 8: Attach the most recent Report of Work Ability form or a narrative report that contains the same information.

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Item 9: Indicate if the employee has reached MMI. If yes, fill in the date MMI was reached. At MMI, permanent partial

disability (PPD) must be reported (see item 10).

Maximum medical improvement means: “The date after which no further significant recovery from or significant lasting

improvement to a personal injury can reasonably be anticipated, based upon reasonable medical probability, irrespective

and regardless of subjective complaints of pain” (Minn. Stat. § 176.011, subd. 13a).

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Item 10: The health care provider must provide an opinion of PPD when ascertainable, but no later than the date of MMI.

Indicate if the employee sustained PPD from this injury. Check one of the three boxes (no, yes, too early to determine).

For dates of injury Jan. 1, 1984, through June 30, 1993, use Minnesota Rules 5223.0010 through 5223.0250. For dates of

injuries July 1, 1993, and later, use rules 5223.0300 through 5223.0650. Report the complete rule number for all ratings,

even if the rating listed is zero. Refer to the specific ratings in Minn. Rules chapter 5223, to determine whether to “add” or

“combine” the ratings. If you have questions about how to assign a rating under the PPD rules, contact the Department of

Labor and Industry at (651) 284-5032 or 1-800-342-5354.

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Identify the health care provider completing the report by name, professional degree, license or registration number,

address and phone number.

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The health care provider must sign and date the report.

This document can be given to you in Braille, large print or audio. To request, call (651) 284-5032 or 1-800-342-5354.

Any person who, with intent to defraud, receives workers’ compensation benefits to which the person is not entitled by

knowingly misrepresenting, misstating or failing to disclose any material fact is guilty of theft and shall be sentenced

pursuant to Minn. Stat. § 609.52, subd.3.

Health Care Provider Report Page 2

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