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DHS-2114-ENG (MDHS Request for Medical Opinion)

DHS-2114-ENG (MDHS Request for Medical Opinion)-2025

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The document is a form from the Minnesota Department of Human Services (DHS) titled 'Request for Medical Opinion' (DHS-2114-ENG). It is used to collect medical information about a client to determine their eligibility for public assistance programs. The form requires the client's personal details and includes an authorization section for releasing medical information. Medical providers are asked to provide insights on the client's health status, treatment plans, and any limitations affecting employment. The document emphasizes the importance of consent for information release and outlines privacy protections.

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Click ‘Get Form’ to open the DHS-2114-ENG in the editor.
Begin by entering the case number, worker name, date, and worker phone number at the top of the form. This information is crucial for tracking your request.
Fill in the medical provider's details including name, clinic address, and fax number. Ensure accuracy to avoid delays in processing.
In the 'Client' section, provide personal information such as client name, date of birth, social security number, and address. This identifies who the medical opinion pertains to.
Review and sign the 'Authorization for Release of Information' section. This grants permission for your medical provider to share necessary information with the agency.
Complete the 'Medical Opinion' section by having your medical provider answer all relevant questions regarding diagnosis and treatment plans.
Finally, ensure that both you and your medical provider electronically sign where indicated before submitting the form.

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What is a medical opinion?

Medical opinions are statements from acceptable medical sources that reflect judgments about the nature and severity of your impairment(s), including your symptoms, diagnosis and prognosis, what you can still do despite impairment(s), and your physical or mental restrictions.

What is a medical opinion form for?

A medical opinion form is used by medical practitioners to collect personal information, medical history, or medical details from patients. With a free online medical opinion form, you can collect the right information from patients right at the point of care!

What is a medical release form used for?

Medical opinion evidence refers to statements or reports from qualified healthcare providers that offer an expert assessment of your medical condition. These opinions typically address key aspects of your illness or injury, such as diagnosis, prognosis, and functional limitations.

What does medical opinion mean?

Who can fill out this form? Healthcare providers, social workers, or family members can complete this form based on their knowledge of the patients situation.