Workers' compensation forms

The forms on this page are PDFs that can be viewed or printed. The forms have been converted to fill-in PDFs that allow users to type directly into the form and then print it. The free Adobe Acrobat Reader software does not allow users the option of saving data that is typed into the fill-in PDF; for the option to save, visit www.adobe.com for more information about Adobe Acrobat software.

Experience faster data entry for dates, phone numbers and Social Security number by entering numbers only. The fill-in PDF will automatically enter the slashes for dates, the parentheses and hyphen for phone numbers and the hyphens for Social Security numbers.

Rehabilitation forms online submission

Rehabilitation provider registration forms

Form name Last update Notes*

R-20 Application for Approval and Registration -- Rehabilitation Consultant Intern March 2012 Technical changes

R-22 Registration or Renewal as a Registered Rehabilitation Vendor March 2012 Technical changes

R-24 Application for Registration or Renewal as Organization Approved for the Employment of Qualified Rehabilitation Consultant/Independent and Tax Notice March 2012 Technical changes

R-25 Application for Renewal of Qualified Rehabilitation Consultant/Intern Registration March 2012 Technical changes

R-21 Qualified Rehabilitation Consultant Service and Fee Notification June 2003 No longer required

R-23 Registered Rehabilitation Vendor Service and Fee Notification June 2003 No longer required

*Notes: DLI = department information updated; PH = phone number change; PO = new mailing address; TENN = Tennessen warning; WID = worker identification (number)**

**Worker identification number -- The department is making an effort to minimize the possibility of data privacy abuse. As part of this effort, DLI will be assigning a worker identification (WID) number to be used on forms and correspondence instead of using the injured worker's Social Security number (SSN). If the injured workers' WID number is not known, the SSN can still be entered in the space on the form, because either number can be used.

More information

Rehabilitation plan service codes and categories
Vocational rehabilitation invoice form
For more information about workers' compensation forms, contact Kathy Hanson in the Compliance, Records and Training unit, at (651) 284-5299 or dli.wcrequest@state.mn.us.

Form name	Last update	Notes*
R-20 Application for Approval and Registration -- Rehabilitation Consultant Intern	March 2012	Technical changes
R-22 Registration or Renewal as a Registered Rehabilitation Vendor	March 2012	Technical changes
R-24 Application for Registration or Renewal as Organization Approved for the Employment of Qualified Rehabilitation Consultant/Independent and Tax Notice	March 2012	Technical changes
R-25 Application for Renewal of Qualified Rehabilitation Consultant/Intern Registration	March 2012	Technical changes
R-21 Qualified Rehabilitation Consultant Service and Fee Notification	June 2003	No longer required
R-23 Registered Rehabilitation Vendor Service and Fee Notification	June 2003	No longer required
Notes: DLI = department information updated; PH = phone number change; PO = new mailing address; TENN = Tennessen warning; WID = worker identification (number)* **Worker identification number -- The department is making an effort to minimize the possibility of data privacy abuse. As part of this effort, DLI will be assigning a worker identification (WID) number to be used on forms and correspondence instead of using the injured worker's Social Security number (SSN). If the injured workers' WID number is not known, the SSN can still be entered in the space on the form, because either number can be used.