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.