Work comp: Form -- Health Care Provider Report

The Health Care Provider Report form is used to:

• determine if the employee has reached maximum medical improvement;

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

• assist the insurer monitoring medical status for a work-related injury;

• keep the commissioner informed of the nature and extent of compensable injuries; and

• comply with statutes and rules:

  • Minnesota Statutes 176.101, subd. 1 (j);

  • Minnesota Statues 176.231, subds. 3, 5, 6 and 7;

  • Minnesota Statutes 176.251; and

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

The form is sent by an employer, an insurer or the commissioner to a health care provider. The employer, insurer or commissioner must complete the identifying information on the top of the form before sending it to the health care provider that must 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.

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

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 or when there is a preliminary or final permanent partial disability rating.