Forms
Click the tabs below to see forms related to each chapter of Division 69L (Workers' Compensation) of the Florida Administrative Code.
Chapter 69L-3: Workers' Compensation Claims
| DFS-F2-DWC-1 (PDF) DFS-F2-DWC-1 (Interactive PDF) |
First Report of Injury or Illness |
| DFS-F2-DWC-1a (PDF) DFS-F2-DWC-1a (Interactive PDF) |
Wage Statement |
| DFS-F2-DWC-3 (PDF) DFS-F2-DWC-3 (Interactive PDF) |
Request for Wage Loss/Temporary Partial Benefits |
| DFS-F2-DWC-4 (PDF) DFS-F2-DWC-4 (Interactive PDF) |
Notice of Action/Change |
| DFS-F2-DWC-12 (PDF) DFS-F2-DWC-12 (Interactive PDF) |
Notice of Denial |
| DFS-F2-DWC-13 (PDF) DFS-F2-DWC-13 (Interactive PDF) |
Claim Cost Report |
| DFS-F2-DWC-14 (PDF) DFS-F2-DWC-14 (Interactive PDF) |
Request for Social Security Disability Benefit Information |
| DFS-F2-DWC-19 (PDF) DFS-F2-DWC-19 (Interactive PDF) |
Employee Earnings Report |
| DFS-F2-DWC-30 (PDF) DFS-F2-DWC-30 (Interactive PDF) |
Authorization and Request for Unemployment Compensation Information |
| DFS-F2-DWC-33 (PDF) DFS-F2-DWC-33 (Interactive PDF) |
Permanent Total Off-Set Worksheet |
| DFS-F2-DWC-35 (PDF) DFS-F2-DWC-35 (Interactive PDF) |
Permanent Total Supplemental Worksheet |
| DFS-F2-DWC-40 (PDF) DFS-F2-DWC-40 (Interactive PDF) |
Statement of Quarterly Earnings for Supplemental Income Benefits |
| DFS-F2-DWC-49 (PDF) DFS-F2-DWC-49 (Interactive PDF) |
Aggregate Claims Administration Change Report |
| DFS-F2-DWC-60 | Important Workers' Compensation Information for Florida's Workers |
| DFS-F2-DWC-61 | Informacion Importante De Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Trabajadores De La Florida |
| DFS-F2-DWC-65 | Important Workers' Compensation Information for Florida's Employers |
| DFS-F2-DWC-66 | Informacion Importante Del Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Empleadores De La Florida |
| IA-1 | First Report of Injury or Illness (ACORD 4 12/1993-EDI carriers use only) Not available for download. |
Chapter 69L-5: Rules for Self-Insurers Under the Workers' Compensation
Act
| DFS-F2-SI-1 | Application for Self-Insurance |
| DFS-F2-SI-1G | Application for Governmental Self-Insurance |
| DFS-F2-SI-4F | Self-Insurer’s Surety Bond for FSIGA Member |
| DFS-F2-SI-5 | Self-Insurer Payroll Report |
| DFS-F2-SI-6 | Self-Insurer’s Irrevocable Letter of Credit |
| DFS-F2-SI-8 | Self-Insurance Employer Application for Drug-Free Workplace Premium Credit Program |
| DFS-F2-SI-9 | Self-Insurance Certification of Workplace Safety Program Premium Credit |
| DFS-F2-SI-10 | Parental Guaranty and Corporate Resolution |
| DFS-F2-SI-11 | Indemnity Agreement |
| DFS-F2-SI-17 | Unit Statistical Report |
| DFS-F2-SI-19 | Certification of Servicing for Self-Insurers |
| DFS-F2-SI-20 | Report of Outstanding Workers’ Compensation Liabilities |
| DFS-F2-SI-22 | Qualified Servicing Entity Application |
| DFS-F2-SI-23 | Qualified Servicing Entity Annual Report |
| DFS-F2-SI-27 | Biographical Statement and Affidavit |
| DFS-F2-SI-GEP | Application for Governmental Self-Insurance Estimated Payroll |
Chapter 69L-6: Workers' Compensation Compliance
Chapter 69L-7: Workers' Comp Medical Reimbursement and Utilization Review
| 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, Effective June 25, 2006 (Rev. 1/31/2008) |
| DFS-F5-DWC-25 (Interactive PDF Format) | Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form, 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@myfloridacfo.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@myfloridacfo.com |
| DFS-F5-DWC-25-A Instructions | Instructions for completion of the DWC-25 (Rev. 01/01/2015) |
DFS-F5-DWC-9 (Rev. 02/12) form required to be submitted for dates of service on or after 02/18/2016 |
|
| 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-A Instructions | Instructions for completion of the DWC-9 when submitted by Licensed Health Care Providers (Rev. 01/01/2015) |
| DFS-F5-DWC-9-B Instructions | Instructions for completion of the DWC-9 when submitted by Work Hardening and Pain Management Programs (Rev. 01/01/2015) |
| DFS-F5-DWC-9-C Instructions | Instructions for completion of the DWC-9 when submitted by Ambulatory Surgical Centers (For use when billing for dates of services through July 7, 2010) (Rev. 01/01/2015) |
DFS-F5-DWC-10 and DFS-F5-DWC-11 forms required to be submitted for dates of service on or after 02/18/2016. |
|
| DFS-F5-DWC-10 | Statement of Charges for Drugs And Medical Supplies Form (Rev. 01/01/2015) |
| DFS-F5-DWC-10-A Instructions | Instructions for completion of the DWC-10 when submitted by pharmacies and home medical equipment providers/suppliers (Rev. 12/08/2015) |
| DFS-F5-DWC-11 | Dental Claim Form (Rev. 2012) - A copy of the DWC-11 can be obtained by contacting the American Dental Association. |
| DFS-F5-DWC-11-A Instructions | Instructions for completion of the DWC-11 for Dentists (Rev. 01/01/2015) |
DFS-F5-DWC-90 form required to be submitted by hospitals on and after 5/23/2007. The DFS-F5-DWC-90 is required to be used by Ambulatory Surgical Centers, Home Health Agencies, and Nursing Home Facilities on and after July 8, 2010. |
|
| DFS-F5-DWC-90 |
Institutional 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-A Instructions for Hospitals | Instructions for completion of the UB-04 (Rev. 12/08/2015) (For use when billing dates of service on or after 02/18/2016) |
| DFS-F5-DWC-90-B Instructions for Ambulatory Surgical Centers | Instructions for completion of the UB-04. (Rev. 12/08/2015) (For use when billing dates of service on or after 02/18/2016) |
| DFS-F5-DWC-90-C Instructions for Home Health Agencies | Instructions for completion of the UB-04. (Rev. 12/08/2015) (For use when billing dates of service on or after 02/18/2016) |
| DFS-F5-DWC-90-D Instructions for Nursing Home | Instructions for completion of the UB-04. (Rev. 12/08/2015) (For use when billing dates of service on or after 02/18/2016) |
Chapter 69L-9: Drug Testing Rule
| NCCI Form 09-01A | Application for Drug-Free Workplace Premium Credit Program |
Chapter 69L-10: Claim For Reimbursement Against Special Disability
Trust Fund
| DFS-F1-SDF-1 | Proof of Claim |
| DFS-F1-SDF-2 | Reimbursement Request |
Chapter 69L-11: Preferred Worker Program
| PW-1 | Preferred Worker Identification Card (Not available for download) |
| DFS-F1-PW-2 | Preferred Worker Reimbursement Request |
Chapter 69L-22: Reemployment Services
| DFS-F3-DWC-23 | Request for Screening |
| DFS-F3-DWC-23 | Instructions |
| DFS-F3-DWC-24 | Department and Student Agreement for Sponsorship of Training and Education |
| DFS-F3-DWC-26 | Department and Injured Employee Agreement for the Provision of Contracted Placement Services |
| DFS-F3-DWC-27 | Reemployment Services Questionnaire |
Chapter 69L-26: Employee Assistance and Ombudsman Office
| PFB | Petition for Benefits can be obtained from the Division of Administrative Hearings website |
| EAO-1 | Request for Assistance |
Chapter 69L-30: Expert Medical Advisors
Chapter 69L-31: Utilization & Reimbursement Dispute Rule
| DFS Form 3160-0023 | Petition for Resolution of Reimbursement Dispute |
| DFS Form 3160-0024 | Carrier Response to Petition for Resolution of Reimbursement Dispute |
Chapter 69L-34: Carrier Report of Health Care Provider Violations
|
DFS-F6-DWC-2000 (PDF Format) |
Health Care Provider Violation Referral Form |
|
DFS-F6-DWC-2000
(Interactive PDF Format) |
Health Care Provider Violation Referral Form |
Chapter 69L-56: Rules For Electronic Data Interchange (EDI) Requirements
for Proof of Coverage and Claims
| DFS-F5-DWC-EDI-1 | EDI Trading Partner Profile (Revised 1/1/2008) |
| DFS-F5-DWC-EDI-2 | EDI Trading Partner Insurer/Claim Administrator ID List (10/1/2006) |
| DFS-F5-DWC-EDI-2A | FL’s Claim Administrator Address List (10/1/2006) |
| DFS-F5-DWC-EDI-3 | EDI Transmission Profile-Sender's Specifications (10/1/2006) |
| DFS-F5-DWC-EDI-4 | Secure Socket Layer (SSL)/File Transfer Protocol (FTP) Instructions (Revised 1/1/2008) |
