Minnesota > Workers Comp
Health Care Provider Report HC01 - Minnesota
| Health Care Provider Report Form. This is a Minnesota form and can be used in Workers Comp . |
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Health Care Provider Report See Instructions on Reverse Side (WHEN COMPLETED RETURN TO REQUESTER) Please PRINT or TYPE your responses. H C 0 1 Enter dates in MM/DD/YYYY format. DO NOT USE THIS SPACE SOCIAL S ECURITY NUMBER DATE OF INJURY EMPLOYEE EMPLOYER INSURER/SELF-INSURER/TPA INSURER CLAIM NUMBER INSU RER ADDRESS CITY STATE ZIP CODE REQUESTER must specify all items to be completed by health care provider. Items: MMI (#9) PPD (#10)HEALTH CARE PROVIDER TO COMPLETE ITEMS REQUESTED ABOVE 1. Date of first examination for this injury by this office: (date) 2. Diagnosis (include all ICD-9-CM codes): 3. History of injury or disease given by employee: 4. In your opinion (as substantiated by the history and physical examination) was the injury or disease caused, aggravated or acce lerated by the employees alleged employment activity or environment? No Yes 5. Is there evidence of pre-existing or other conditions that affect this disability? No Yes If yes, describe: 6. Is further treatment of this injury or referral to another doctor planned? No Yes If yes, describe: 7. Has surgery been performed? No Yes If yes, date and describe: (date)8. Attach the most recent Report of Work Ability. Date of report: (date) 9. Has the employee reached maximum medical improvement? Date No Yes (If yes, complete item #10) (See definition on back) reached: 10. Has the employee sustained any permanent partial disability from the injury? No Yes Too early to determine The permanent partial disability is % of the whole body. This rating is based on Minn. Rules: 5223. % 5223. % 5223. % 5223. %NAME (Type or Print) SIGNATURE DEGREE ADDRESS STATE LICENSE #/REGISTRATION # CITY STATE ZIP CODE AREA CODE TELEPHONE # DATE SIGNED MN HC01 (7/01) <<<<<<<<<********>>>>>>>>>>>>> 2NOTICE TO EMPLOYEE: SERVICE OF THIS REPORT OF MAXIMUM MEDICAL IMPROVEMENT (SEE DEFINITION ININSTRUCTIONS FOR ITEM 9) MAY HAVE AN IMPACT ON YOUR TEMPORARY TOTAL DISABILITY WAGE LOSS BENEFITS. IF THE INSURER PROPOSES TO STOP YOUR BENEFITS, A NOTICE OF INTENTION TO DISCONTINUE BENEFITS SHOULD BESENT TO YOU. IF YOU HAVE ANY QUESTIONS CONCERNING YOUR BENEFITS OR MAXIMUM MEDICAL IMPROVEMENT,YOU MAY CALL THE CLAIM REPRESENTATIVE OR THE DEPARTMENT OF LABOR AND INDUSTRY, WORKERSCOMPENSATION DIVISION AT (651) 284-5030 OR 1-800-342-5354. INSTRUCTIONS TO THE INSURER AND HEALTH CARE PROVIDER Within ten (10) calendar days of receipt of a request for info rmation on the Health Care Provider Report from an employer,insurer, or the commissioner, a health care provider must respond on the report form or in a narrative report that contains thesame information. (Minn. Rules 5221.0410, subp. 2) A. The employer, insurer, or Commissioner may request required medical information on the Health Care Provider Report form. ! The requester must complete the general information identifying the employee, employer, and insurer. ! The requester must specify all items to be answered by the health care provider. ! For those injuries that are required to be reported to the Divi sion, the self-insured employer or insurer must file reports with the Division. (M.S. 176.231, subd. 1 and Minn. Rules 5221.0410, subp. 5 and subp. 8) ! The self-insured employer or insurer must serve the re port of maximum medical improvement (MMI) on the employee. (M.S. 176.101, subd. 1(j) and Minn. Rules 5221.0410, subp. 3) B. Instructions to the Health Care Provider for completing the Health Care Provider Report: ! Items 1 - 5: Fill in all information as required. ! Item 6: Indicate if further treatment or referral is planned. Describe the treatme nt plan (e.g., continue medication, refer to physical therapy, refer to a specialist, perform surgery). ! Item 7: State if surgery has been performed. If yes, fill in the date performed and describe the procedure. ! Item 8: Attach the most recent Report of Work Ability. (Minn. Rules 5221.0410, subp. 6) ! Item 9: Indicate if the employee has reached MMI. If ye s, fill in the date MMI was reached. At MMI, permanent partial disability (PPD) must be reported (item 10). (M.S. 176.011, subd. 25 and Minn. Rules 5221.0410, subp. 3) MAXIMUM MEDICAL IMPROVEMENT means "The date after wh ich no further significant recovery from or significant lasting improvement to a personal injury can reasonably be anticipated, based upon reasonable medical probability, irrespective and regardless of subjective complaints of pain." ! Item 10: The health care provider must render an opinion of PPD when ascertainable, but no later than the date of MMI. (M.S. 176.011, subd. 25 and Minn. Rules 5221.0410, subp. 4) Indicate if the employee sustained PPD from this injury. Check one of the three boxes (too early to determine, no, yes). If yes, specify any applicable category of the PPD sc hedule in effect for the employees date of injury. Report any zero ratings. ! Identify the health care provider completing the report by name, professional degree, license or registration number, address, and phone number. ! The health care provider must sign and date the report. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651)284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS COMPENSATION BENEFITS TO WHICH THE PERSON IS NOTENTITLED BY KNOWINGLY MISREPRES ENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT ANDSHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
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