The 36 Minnesota forms clinicians complete, from Paid Leave certifications and workers' comp reports to DVS driver and parking forms, drug prior authorization and the POLST.
This page lists the Minnesota forms clinicians complete, grouped by program, and each group links to its program hub. Minnesota Paid Leave, which began paying benefits on January 1, 2026, has certification forms for medical, pregnancy-related and caring leave. Workers' comp brings the HC01 Health Care Provider Report and the RW01 Report of Work Ability. Driver and Vehicle Services uses PS30338 for vision and PS2005 for disability parking certificates. Every payer must accept the Minnesota Uniform Form for Prescription Drug Prior Authorization.
Paid Leave also accepts an FMLA certification such as the WH-380-E if it has all the required information. The RW01 goes to the employee at each visit. PS2005 also asks whether the patient is medically qualified to drive. School immunization medical exemptions are signed on the back of the state's K-12 requirement sheet, and MSRS disability claims need two medical statements, one from an MD. Of these forms, 3 have a Spanish version. Vero Documents fills PDF forms from the visit note and the chart.
Narrative medical report on diagnosis, causation, treatment, restrictions, maximum medical improvement (MMI) and permanent partial disability (PPD) rating, as requested by the insurer.
Reports whether the injured employee can work without restrictions, with restrictions, or not at all, and the dates, after each visit.
Optional model agreement between prescriber and injured worker required before long-term opioid treatment under Minnesota's workers' compensation treatment parameters.
Certifies the applicant's own serious health condition, start date and length, leave schedule (continuous/intermittent with episode frequency) and affected job functions for Minnesota Paid Leave medical leave.
Certifies a family member's serious health condition and the care and schedule the applicant needs for Minnesota Paid Leave caring (family) leave.
Certifies pregnancy-related incapacity, prenatal care or recovery from childbirth for Minnesota Paid Leave medical leave.
Health care provider certification for an employer's Unum-insured private plan under Minnesota Paid Family and Medical Leave.
Certifies that the applicant or a family member needs safety leave related to domestic abuse, sexual assault or stalking under Minnesota Paid Leave.
Optional provider confirmation that a child was born, the date of birth and the parents, for Minnesota Paid Leave bonding leave when no birth certificate or discharge record is available.
Medical report on the member's condition required (two reports, same condition) for a TRA total and permanent disability benefit.
Medical professional documents the disabling condition (ICD code), onset, findings, treatment, prognosis and psychiatric/physical capabilities, and whether the employee is disabled under the Correctional Retirement Plan definition, for an MSRS disability benefit.
Medical professional documents the disabling condition (ICD code), onset, findings, treatment, prognosis and psychiatric/physical capabilities, and whether the employee is disabled under the General Employees Retirement Plan definition, for an MSRS disability benefit.
Medical professional documents the disabling condition (ICD code), onset, findings, treatment, prognosis and psychiatric/physical capabilities, and whether the employee is disabled under the State Patrol Retirement Plan definition, for an MSRS disability benefit.
PS30338Licensed vision examiner's report of visual acuity and recommended restrictions for a driver who did not pass DVS vision screening.
Physician's report used to determine a driver's eligibility after loss of consciousness or voluntary control (seizures, syncope, diabetic episodes), including the review interval.
Ophthalmologist's report on whether diabetes has affected the eye health (e.g. unstable proliferative retinopathy) of an applicant for an intrastate school bus driver medical waiver.
Supports a restricted license for a 15-year-old to drive for personal medical reasons or to drive a relative for medical reasons or due to a disability (Minn. Stat. 171.042).
Requests DVS reexamination of a driver for physical, mental, diabetic or seizure-related loss of control, vision or knowledge/skill problems.
Applies for a temporary, short-term, long-term or permanent disability parking certificate (hangtag), with a health professional's certification under Minn. Stat. 169.345 and whether the patient is medically qualified to drive.
Professional verification of the applicant's condition and functional limits, submitted with the Certification Questionnaire to decide ADA paratransit (Metro Mobility) eligibility in the Twin Cities.
Supplemental medical necessity documentation for wheelchair, scooter and mobility device authorization requests.
DHS-4695General paper authorization (prior authorization) request for Minnesota Health Care Programs fee-for-service services and equipment, used when the MN-ITS authorization transaction is not used.
MS-2083Health care source's summary of a child's physical exam and health status required at enrollment in a Minnesota licensed child care center (Minn. R. 9503.0070).
Sports qualifying physical exam and clearance required for MSHSL athletic participation.
ID# 52799Minnesota K-12 immunization requirement sheet whose reverse side documents a medical exemption (provider-signed), a notarized non-medical exemption, or history of chickenpox.
Plan De Accion Para Asma - para el niño
Pediatric green/yellow/red asthma action plan that also authorizes school/daycare administration of the listed medicines and records whether the child may self-carry a quick-relief inhaler.
Exhibit 7-DMedical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Portable provider order for CPR, treatment intensity and artificial nutrition for seriously ill or frail Minnesotans.
Attending physician's statement of diagnosis, prognosis and behavioral evidence supporting a guardianship/conservatorship petition, with an optional opinion that the respondent cannot attend the hearing.
Registered practitioner certifies that a Minnesota resident has a qualifying medical condition and attests to managing it on an ongoing basis, triggering the patient's enrollment application.
Provider case report of chlamydia or gonorrhea with treatment information.
General report of a case of most reportable infectious diseases in a Minnesota resident.
Provider case report of syphilis (stage, treatment, pregnancy status) for public health follow-up.
Physician verification of a permanent physical disability so the hunter can add a Type 2 Disabled Hunter endorsement to a Minnesota driver's license/ID (used for special disabled-hunter seasons).
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Yes, if it includes all the information Minnesota Paid Leave requires, and employer forms are reviewed case by case. The state's own Medical Leave Certification Form asks the provider for the condition, start date and length, a continuous or intermittent schedule with episode frequency, and the job functions affected. The applicant or the provider can upload, fax or mail it. Caring leave and pregnancy-related leave have their own forms.
The health care provider directing treatment, such as an MD, DO, chiropractor, PA or APRN. The RW01 states whether the employee can work without restrictions, with restrictions or not at all, with dates. The provider gives it to the employee at each visit, and a report is also due within 10 days of an insurer request and when restrictions expire. A report with the same content can substitute.
A licensed physician, physician assistant, APRN, chiropractor or physical therapist completes Part B of PS2005. The certificate can be temporary, short-term, long-term or permanent, and Part B also asks whether the patient is medically qualified to control a motor vehicle. The applicant applies at any deputy registrar office or by mail to Driver and Vehicle Services. Long-term and permanent certificates have no fee.
An MD, DO, PA or APRN completes Sections A to C with the patient or representative and signs as the provider. The form records CPR, treatment intensity and artificial nutrition orders and stays with the patient. Minnesota has no POLST statute, so the Minnesota Medical Association maintains the form. The current version dates from 2017, and earlier Minnesota versions remain valid.