-F5-DWC-10 Rev. 1/1/2015 Rule 69L-7.720, F.A.C. FLORIDA DEPARTMENT OF FINANCIAL SERVICES - DIVISION OF WORKERS' COMPENSATION . STATEMENT OF CHARGES FOR DRUGS AND MEDICAL EQUIPMENT & SUPPLIES . Pharmacists & Medical Suppliers - Must complete this billing form in detail to file for reimbursement of services.

2015年12月8日 · Enter the injured employee’s Social Security or Division-Assigned Number. Contact the insurer/claim administrator to obtain the Division-Assigned Number if unknown and if there is no known Social Security Number. Enter the date of accident, illness or injury, for which services are rendered, in MM/DD/YYYY format.

Health Provider Claim Form/CMS-1500 - A copy of the DWC-9 can be obtained from the CMS website. DFS-F5-DWC-10 and DFS-F5-DWC-11 forms required to be submitted for dates of service on or after 02/18/2016. Dental Claim Form (Rev. 2012) - A copy of the DWC-11 can be obtained by contacting the American Dental Association.

DWC/ WCAB Form 10 (Page 1) (REV. 11/2008 ) WCAB10 . Claims Administrator Information (if applicable) Name (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or …

The proposed rules represent a substantial rewrite and reorganization of Rule 69L-7.710, F.A.C., (formerly Rule 69L-7.602, F.A.C.), titled, “Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule.” ....

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