Report Of Work Ability Form PDF Details

In the realm of workers' compensation, communication about an employee's ability to work after an injury is critical for all parties involved—the worker, the employer, and the insurer. The Minnesota Department of Labor and Industry has streamlined this communication with the Report Of Work Ability form, a tool designed to provide clear documentation of an injured employee’s work status. This form, part of the procedural fabric of workers' compensation claims, serves multiple crucial functions. It conveys whether an employee can return to work without restrictions, can work with specific limitations, or is unable to work for a designated period. Health care providers evaluating injured workers are tasked with completing and issuing this report within a defined timeframe, dependent on the frequency of medical visits or any change in the worker's restrictions. Detailed instructions on the reverse side of the form guide the health care provider through the process, ensuring that all necessary information—ranging from identification details of the employee and employer to specific work restrictions—is accurately captured. Furthermore, this document must reach the employee, be included in the medical record, and be shared with the relevant workers’ compensation parties, underscoring its role in facilitating the appropriate and timely delivery of workers’ compensation benefits. This process not only aids in the transparent communication among all stakeholders but also upholds the integrity of the workers’ compensation system by setting forth clear guidelines to prevent any fraudulent claims. By detailing the protocol for reporting work ability, the state aims to ensure that injured employees receive the support they need while also protecting employers and insurers from potential misuse of benefits.

QuestionAnswer
Form NameReport Of Work Ability Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameswhat is a work a bility form, INSURER, workability form, worability form

Form Preview Example

Minnesota Department of Labor and Industry Workers’ Compensation Division www.dli.mn.gov/wc/wcforms,asp

Report of Work Ability

See Instructions of Reverse Side

R W 0 1

PRINT IN INK or TYPE

Enter dates in MM/DD/YYYY format.

This form must be provided to the employee. (Minn. Rules 5221.0410,l subd. 6)

NOTICE TO EMPLOYEE: YOU MUST PROMPTLY PROVIDE A COPY OF THIS REPORT TO YOUR EMPLOYER OR WORKERS’ COMPENSATION INSURER, AND QUALIFIED REHABILITATION CONSULTANT IF YOU HAVE ONE.

WID or SSN

DATE OF INJURY

 

 

EMPLOYEE

EMPLOYER

INSURER/SELF-INSURER-TPA

INSURER CLAIM NUMBER

DO NOT USE THIS SPACE

Date of most recent examination by this office

 

 

 

 

 

 

Select the appropriate option(s) below and fill in the applicable dates.

 

 

 

 

 

1.

Employee is able to work without restrictions as of

 

 

 

(date)

 

2.

Employee is able to work with restrictions, from

 

(date) to

(date)

 

The restrictions are:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Employee is unable to work from

 

 

 

 

 

(date) to

 

 

(date)

 

 

 

 

 

 

 

 

 

 

 

 

 

The next scheduled visit is:

as needed

OR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME (Type or Print)

 

 

 

 

SIGNATURE

 

DEGREE

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

STATE

LICENSE #/REGISTRATION #

 

 

 

 

 

 

 

CITY

 

STATE

ZIP CODE

PHONE # (include area code)

DATE SIGNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MN RW01 (7/10)

INSTRUCTIONS FOR COMPLETING REPORT OF WORK ABILITY

Each health care provider directing the course of treatment for an employee who alleges to have incurred an injury on the job must complete a Report of Work Ability within 10 days of a request for a Report of Work Ability from the insurer, or at the applicable interval (Minn. Rules 5221.0410, subp. 6):

1.every visit if visits are less frequent that one every two weeks;

2.every 2 weeks if visits are more frequent than once every two weeks, unless work restrictions change sooner; and

3.upon expiration of the ending or review date of the restrictions specified in a previous Report of Work Ability.

The Report of Work Ability must either be on this form or in a report that contains the same information. The Report of Work Ability must:

Identify the employee by name, WID or social security number, and date of injury.

Identify the employer at the time of the employee’s claimed work injury.

If known, identify the workers’ compensation insurer at the time of the claimed injury, or the workers’ compensation third-party administrator. Also indicate this workers’ compensation payer’s claim number.

Indicate the date of the most recent examination by this office. The Report of Work Ability should be completed based on this evaluation.

Identify the appropriate option which best describes the employee’s current ability to work by checking box 1, 2, or 3.

1.If the employee is able to work without restrictions, fill in the beginning date.

2.If the employee is able to work with restrictions, fill in the date any restriction of work activity is to begin and the anticipated ending or review date. Describe any restrictions in functional terms (e.g., employee can lift up to 20 pounds, 15 times per hour; should have 10 minute break every hour).

3.If the employee is unable to work at all, fill in the date the restriction of work activity is to begin and the anticipated ending or review date.

Indicate the date of the next scheduled visit or indicate that additional visits will be scheduled as needed.

Identify the health care provider completing the report by name, professional degree, license or registration number, address and phone number.

Include the signature of the health care provider and date of the report.

The health care provider must provide the Report of Work Ability to the employee and place a copy in the medical record.

If you have questions, please call the claim representative or the Department of Labor and Industry, Workers’ Compensation Division at (651) 284-5030 or 1-800-342-5354.

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 NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

How to Edit Report Of Work Ability Form Online for Free

It is possible to complete workability report form effectively with the help of our PDFinity® online tool. The editor is continually maintained by us, receiving awesome functions and turning out to be better. This is what you'll have to do to get started:

Step 1: Click on the "Get Form" button above on this webpage to open our PDF editor.

Step 2: Once you access the online editor, you will notice the form made ready to be filled out. Apart from filling in different fields, you can also perform many other things with the form, particularly putting on your own words, editing the original text, inserting illustrations or photos, signing the PDF, and a lot more.

This PDF requires particular info to be entered, therefore you must take your time to provide what's required:

1. Begin filling out your workability report form with a selection of essential fields. Consider all the information you need and ensure not a single thing left out!

Step number 1 for completing Minnesota

2. Once your current task is complete, take the next step – fill out all of these fields - The restrictions are, Employee is unable to work from, date, date, The next scheduled visit is, as needed OR, NAME Type or Print, SIGNATURE, DEGREE, ADDRESS, STATE, LICENSE REGISTRATION, CITY, STATE, and ZIP CODE with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Minnesota writing process detailed (portion 2)

People frequently make some mistakes when filling out as needed OR in this part. Ensure that you read again everything you enter here.

Step 3: Immediately after taking another look at your fields and details, press "Done" and you're done and dusted! Acquire your workability report form once you join for a free trial. Readily access the pdf in your personal account page, with any modifications and adjustments conveniently synced! Here at FormsPal, we strive to be certain that your details are stored secure.