The Minnesota DHS-2114 form, formally called the Request for Medical Opinion, is the document a qualified medical professional signs to certify that an illness, injury, or incapacity prevents you from working. You use it to establish disability-based eligibility for General Assistance and certain Housing Support cases. Download it from the Minnesota Department of Human Services eDocs portal, have your provider complete and sign it, then submit it to your county or tribal human services office with your benefit application.
Which Programs Accept the DHS-2114
The form is built for two programs. General Assistance pays monthly cash to single adults and childless couples who cannot support themselves through work. To qualify based on health, you need a professionally certified illness, injury, or incapacity expected to last more than 45 days that keeps you from getting or keeping a job.1Minnesota Office of the Revisor of Statutes. Minnesota Statutes Chapter 256D If you have a pending Social Security disability application, or you are appealing a termination of Social Security disability benefits, that threshold drops to 30 days. A signed DHS-2114 is one of the accepted ways to supply that certification.2Minnesota Department of Human Services. Combined Manual – Verifying Disability/Incapacity – Cash
Housing Support, formerly known as Group Residential Housing, pays for room and board at approved settings for adults with disabilities or those over 65.3Minnesota Department of Human Services. Housing Support If you are not already receiving Social Security disability or SSI, you can establish eligibility using the same GA categories under Minnesota Statutes 256D.05, and a signed DHS-2114 serves as proof.4Minnesota Office of the Revisor of Statutes. Minnesota Statutes Chapter 256I – Housing Support An alternative, the Professional Statement of Need (DHS-7122), is used when you already live in a Housing Support setting.2Minnesota Department of Human Services. Combined Manual – Verifying Disability/Incapacity – Cash
A quick boundary: Minnesota Supplemental Aid uses different verification. MSA eligibility runs through your SSI or Social Security disability status, or through a State Medical Review Team determination, not the DHS-2114.2Minnesota Department of Human Services. Combined Manual – Verifying Disability/Incapacity – Cash If you are applying for MSA, ask your county worker which documentation applies before filling out anything.
Who Is Allowed to Sign the Form
Minnesota defines a “professional certification” as a statement about illness, injury, or incapacity signed by a “qualified professional.”5Minnesota Office of the Revisor of Statutes. Minnesota Statutes Chapter 256D – Section 256D.02 That includes licensed physicians (M.D. or D.O.), physician assistants, advanced practice registered nurses such as nurse practitioners, and licensed psychologists for mental health or cognitive conditions. Each must be acting within the scope of practice defined by their licensing board.
The professional who actually evaluated you is the one who signs. Office staff, medical assistants, and administrative clerks cannot sign on a provider’s behalf, and a form signed by someone outside the qualified professional definition will be rejected. If your regular provider does not qualify, ask the supervising physician at the same clinic to review your records and sign.
What the Completed Form Must Include
Download the form from the Minnesota DHS eDocs portal by searching for “DHS-2114.” Print it or use the fillable version, then bring it to your appointment. Most of the form is for your provider to complete; your role is supplying identifying information and making sure the visit addresses each required field.
The Combined Manual requires every completed form to contain:2Minnesota Department of Human Services. Combined Manual – Verifying Disability/Incapacity – Cash
- The signing professional’s name and full credentials.
- The date of your most recent exam. This anchors the certification period. If the date is missing or more than six months old, the certification runs from the signature date instead.
- The primary diagnosis preventing you from working, plus any secondary diagnoses contributing to your functional limitations.
- The anticipated duration of the condition. If the provider gives no end date, the certification is valid for one year from signing.
- Permanent physical or mental limitations, described specifically. Think along the lines of inability to stand for extended periods, lift certain weights, concentrate, or interact socially in a work environment.
- Treatment plan status, including whether one exists and whether you are following it. Noncompliance can affect eligibility.
- Work limitations, meaning what type and amount of work you can or cannot do. State evaluators rely on this section most heavily.
Your provider should cross-reference diagnostic tests, treatment history, and exam findings for each field. Vague statements like “patient is unable to work” without clinical support are the single most common reason forms come back for clarification. Specific functional limitations move the review along.
How Long the Certification Lasts
A DHS-2114 does not stay valid forever, and the window depends on your condition.2Minnesota Department of Human Services. Combined Manual – Verifying Disability/Incapacity – Cash
- Standard certifications are valid for six months from the date of the last examination, unless the provider specifies a different timeframe.
- If the provider certifies the condition as permanent and you cannot perform any employment in the foreseeable future, the certification is valid for one year.
- If the exam date is missing or already more than six months old when the form reaches the agency, the certification runs from the date the professional signed.
Your county worker will usually notify you when a new medical opinion is needed to continue benefits. Schedule the follow-up appointment before that notice arrives so you don’t lose a payment while chasing paperwork.
Submitting the Form
Once the form is signed and dated, send it to the human services office in your county or tribal service area.6Minnesota Department of Human Services. General Assistance Most county offices accept the form by fax, secure mail, in-person drop-off, or a drop box. Some accept scanned forms by email.7Brown County, MN. Human Services Check your local office’s preferred method, because procedures vary.
Some clinics will send the form to the agency for you. Even then, follow up with your county worker within a few days to confirm receipt. Keep a copy before anything leaves the clinic — the form carries sensitive medical information.
What Happens After You Submit
A caseworker reviews the medical opinion alongside your income and resource information. Processing times vary by county and caseload, and no single statewide deadline covers every GA decision. If the review is dragging, ask your caseworker for a status update rather than resubmitting the form.
If you are in an immediate crisis while waiting on the GA decision, Emergency General Assistance may cover basic needs for up to 30 days. EGA exists to bridge significant delays in the GA determination.8Minnesota Department of Human Services. Emergency General Assistance (EGA) Raise EGA with your caseworker at the time you apply if you need help with rent, utilities, or other essentials right away.
If the form lacks specific functional detail, the agency may request additional documentation or clarification from your provider before deciding. You will receive the decision in writing by mail, explaining whether the medical opinion established a valid basis for eligibility.
When SMRT Replaces the DHS-2114
The DHS-2114 is not the only route. The State Medical Review Team makes disability determinations for people who have not been certified as disabled by the Social Security Administration.9Minnesota Department of Human Services. The State Medical Review Team (SMRT) SMRT is used primarily for Medical Assistance, home and community-based waiver programs, and certain trust requirements, not for GA directly. If SMRT has already issued a disability determination for another program, your county agency can accept it as proof for GA or Housing Support, and you would not need a separate DHS-2114.2Minnesota Department of Human Services. Combined Manual – Verifying Disability/Incapacity – Cash
You cannot contact SMRT directly. Your county or tribal servicing agency initiates the referral, so talk to your caseworker if you think SMRT fits your situation better.
If the Agency Denies You
If your application is denied because the agency finds the medical opinion insufficient, you can appeal by filing form DHS-0033, Appeal to State Agency, with the DHS Appeals Division.10Minnesota Department of Human Services. Appeal to State Agency You can submit it by mail, fax, in person, or online, and most appeal requests must be in writing.11Minnesota Department of Human Services. Appeals
For GA, Housing Support, and most non-SNAP programs, a hearing decision can take up to 90 days from the date you file. That can stretch further if either side requests a continuance or the judge allows more time for evidence.11Minnesota Department of Human Services. Appeals Use the denial letter as a roadmap: it will tell you what the agency found lacking, which guides what additional medical records, test results, or a revised DHS-2114 with sharper functional detail you need to gather.
Penalties for False Information
Submitting false medical information on a DHS-2114 to obtain benefits you are not entitled to is treated as theft of public funds. Anyone who obtains or attempts to obtain assistance through willfully false statements, concealment of material facts, or impersonation is guilty of theft and sentenced based on the value of the benefits wrongfully received. A person convicted of welfare fraud is also disqualified from the program for one year after a first offense, two years after a second, and permanently after a third.12Minnesota Office of the Revisor of Statutes. Minnesota Statutes 256.98 – Wrongfully Obtaining Assistance These penalties reach anyone who aids the fraud, and a provider who knowingly signs a false DHS-2114 faces professional licensing consequences on top of possible criminal liability.