| DFS-F5-DWC-25 forms required since 6/25/2006. |
| 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) |
| 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 |
| DFS-F5-DWC-9
Instructions |
Instructions for completion of the DWC-9
When submitted by Ambulatory Surgical Centers |
| DFS-F5-DWC-9
Instructions |
Instructions for completion of the DWC-9
When submitted by Licensed Health Care Providers |
| 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. |
| 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. |
| 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
|
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.) |
| DFS-F5-DWC-90
Instructions |
Instructions for completion of the UB-04. |
|
| AHCA
Form 3160-0020 |
Health Care Provider Application for Certification |
| AHCA
Form 3160-0021 |
Expert Medical Advisor Application and Contract For
Certification |
| Tutorial [1.5MB
PowerPoint] |
Health Care Provider Tutorial for Expert Medical Advisor
certification |
| AHCA
Form 3160-0023 |
Petition for Resolution of Reimbursement Dispute |
| AHCA
Form 3160-0024 |
Carrier Response to Petition for Resolution of Reimbursement
Dispute |
| 59A-31
Rules |
AHCA Health Facility and Agency Licensing 59A-31Disputed
Reimbursement Rules |
