| DFS-F5-DWC-25 forms required since 6/25/2006. |
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DFS-F5-DWC-25
(PDF Format) |
Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form and Instructions, Effective June 25, 2006 (Rev. 1/31/2008) |
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DFS-F5-DWC-25
(Interactive PDF Format) |
Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form and Instructions, Effective June 25, 2006 (Rev. 1/31/2008) |
|
DFS-F5-DWC-25
(Interactive Excel Format) Please see saving instructions to the right. |
Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form, Effective June 25, 2006 (Rev. 1/31/2008)
-To access the interactive form, right click the link. Select "save target as" to save the form in your personal files. Macros MUST be "enabled". Questions or difficulties encountered when using the form should be directed to the Workers' Compensation Medical Services Unit via email at
Workers.MedService@fldfs.com |
|
DFS-F5-DWC-25
(Word Format) Please see saving instructions to the right. |
Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form, Effective June 25, 2006 (Rev. 1/31/2008)
- To access the form in Word format, right click the link. Select "save target as" to save the form as a Word document in your personal files. After saving it as a Word file, you may also save it as a Word template. Questions or difficulties encountered when using the form should be directed to the Workers' Compensation Medical Services Unit via e-mail at
Workers.MedService@fldfs.com |
|
DFS-F5-DWC-25 Instructions |
Instructions for completion of the DWC-25, Effective June 25, 2006 (Rev. 1/31/2008) |
DFS-F5-DWC-9 (Rev. 08/05) form required to be submitted for dates of service on or after June 1, 2007 |
| DFS-F5-DWC-9 |
Health Provider Claim Form/CMS-1500 - A copy of the DWC-9 can be obtained from the
CMS website |
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DFS-F5-DWC-9 Instructions |
Instructions for completion of the DWC-9
When submitted by Ambulatory Surgical Centers |
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DFS-F5-DWC-9 Instructions |
Instructions for completion of the DWC-9
When submitted by Licensed Health Care Providers |
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DFS-F5-DWC-9 Instructions |
Instructions for completion of the DWC-9
When submitted by Work Hardening and Pain Management Programs |
DFS-F5-DWC-10 and DFS-F5-DWC-11 forms required to be submitted for Dates of Service on and after 4/1/2007. |
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DFS-F5-DWC-10 |
Statement of Charges for Drugs And Medical Supplies Form and Instructions |
| DFS-F5-DWC-11 |
Dental Claim Form (Rev. 2006) - A copy of the DWC-11 can be obtained by contacting the American Dental Association. |
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DFS-F5-DWC-11 Instructions |
Instructions for completion of the DWC-11 |
DFS-F5-DWC-90 form required to be submitted on and after 5/23/2007. |
DFS-F5-DWC-90
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Hospital Billing Form (UB-04) - A copy of the DWC-90 can be obtained from the
CMS website (PLEASE NOTE THIS FORM IS NOT AVAILABLE ON THE CMS WEBSITE AT THIS TIME.) |
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DFS-F5-DWC-90 Instructions |
Instructions for completion of the UB-04. |
