Minnesota insurers, employers or the commissioner use this report to get specific medical information from a treating provider in a workers' compensation claim. The requester fills in the claim details and marks which items the provider must answer: diagnosis with ICD-10-CM codes, history, causation, pre-existing conditions, planned treatment, surgery, restrictions, maximum medical improvement (MMI), and permanent partial disability (PPD) rated under Minnesota Rules chapter 5223.
The requester completes the identifying section and specifies the items to answer. The treating health care provider completes those items and signs with name, degree and license or registration number.
Download the current version from the source each time; forms change without notice.
Health Care Provider Report
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.
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Within 10 calendar days of receiving the request, under Minnesota Rules 5221.0410. The provider may answer on the form or in a narrative report that covers the items the requester marked, and must sign and date it.
Maximum medical improvement is defined in Minn. Stat. 176.011, subd. 13a as the date after which no further significant recovery or lasting improvement can reasonably be anticipated, based on reasonable medical probability, regardless of subjective complaints of pain. If you mark MMI reached, item 10 on PPD must be completed.