Florida Workers' Compensation Uniform Medical Treatment/Status Report Form (DFS-F5-DWC-25)
The provider must complete form DFS-F5-DWC-25 to request authorization for a medical treatment plan, to communicate to the carrier an injured employee’s medical status, to document the injured employee’s date of Maximum Medical Improvement (MMI date), and to document a Permanent Impairment Rating (PI Rating).
Note: Only a physician can determine MMI or assign a PI Rating per subsection 440.15(3), F.S.
| DFS-F5-DWC-25 (PDF) | 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) |