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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

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DFS-F2-DWC-1 (PDF) DFS-F2-DWC-1 (Interactive PDF)

First Report of Injury or Illness

DFS-F2-DWC-1a (PDF) Wage Statement DFS-F2-DWC-1a (Interactive PDF) 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) Notice of Denial DFS-F2-DWC-12 (Interactive PDF) DFS-F2-DWC-13 (PDF) Claim Cost Report DFS-F2-DWC-13 (Interactive PDF) DFS-F2-DWC-14 (PDF) Request for Social Security Disability Benefit DFS-F2-DWC-14 (Interactive PDF) Information DFS-F2-DWC-19 (PDF) Employee Earnings Report DFS-F2-DWC-19 (Interactive PDF) DFS-F2-DWC-30 (PDF) Authorization and Request for Unemployment DFS-F2-DWC-30 (Interactive PDF) Compensation Information DFS-F2-DWC-33 (PDF) Permanent Total Off-Set Worksheet DFS-F2-DWC-33 (Interactive PDF) DFS-F2-DWC-35 (PDF) Permanent Total Supplemental Worksheet DFS-F2-DWC-35 (Interactive PDF) DFS-F2-DWC-40 (PDF) Statement of Quarterly Earnings for Supplemental DFS-F2-DWC-40 (Interactive PDF) Income Benefits DFS-F2-DWC-49 (PDF) Aggregate Claims Administration Change Report DFS-F2-DWC-49 (Interactive PDF) 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

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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

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DWC 250

Notice of Election to be Exempt

DWC 250-R

Revocation of Election to be Exempt

DWC 251

Notice of Election of Coverage

DWC 251-R

Revocation of Election of Coverage

CHAPTER 69L-7: WORKERS' COMP MEDICAL REIMBURSEMENT AND UTILIZATION REVIEW

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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)

Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form, Effective June 25, 2006 (Rev. 1/31/2008) DFS-F5-DWC-25 -To access the interactive form, right click the link. Select (Interactive Excel Format) "save target as" to save the form in your personal files. Macros Please see saving MUST be "enabled". Questions or difficulties encountered instructions to the right. when using the form should be directed to the Workers' Compensation Medical Services Unit via email at [email protected] 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 DFS-F5-DWC-25 (Word "save target as" to save the form as a Word document in your Format) Please see saving personal files. After saving it as a Word file, you may also save instructions to the right. 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 [email protected] 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 Health Provider Claim Form/CMS-1500 - A copy of the DWC-9

DFS-F5-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

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NCCI Form 09-1 Application for Drug-Free Workplace Premium Credit Program CHAPTER 69L-10: CLAIM FOR REIMBURSEMENT AGAINST SPECIAL DISABILITY TRUST FUND

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DFS-F1-SDF-1

Proof of Claim

DFS-F1-SDF-2

Reimbursement Request

CHAPTER 69L-11: PREFERRED WORKER PROGRAM

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PW-1

Preferred Worker Identification Card (Not available for download)

DFS-F1-PW-2

Preferred Worker Reimbursement Request

CHAPTER 69L-22: REEMPLOYMENT SERVICES

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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

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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

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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

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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

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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)

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Forms - Florida Department of Financial Services

MYFLORIDACFO.COM > DIVISION > WC > PUBLICATIONSFORMSMANUALSREPORTS > FORMS > Forms Click the tabs below to see forms related to each chapter of Divis...

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