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Division Director

Tanner Holloman

Assistant Director

Andrew Sabolic


Workers' Compensation
200 East Gaines Street
Tallahassee, FL 32399-0318
Workers' Compensation Claims
(800) 342-1741
Workers' Compensation Exemption/ Compliance
(850) 413-1609

Forms

All forms are in PDF Format PDF

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 First Report of Injury or Illness
DFS-F2-DWC-1a Wage Statement
DFS-F2-DWC-3 Request for Wage Loss/Temporary Partial Benefits
DFS-F2-DWC-4 Notice of Action/Change
DFS-F2-DWC-12 Notice of Denial
DFS-F2-DWC-13 Claim Cost Report
DFS-F2-DWC-14 Request for Social Security Disability Benefit Information
DFS-F2-DWC-19 Employee Earnings Report
DFS-F2-DWC-30 Authorization and Request for Unemployment Compensation Information
DFS-F2-DWC-33 Permanent Total Off-Set Worksheet
DFS-F2-DWC-35 Permanent Total Supplemental Worksheet
DFS-F2-DWC-40 Statement of Quarterly Earnings for Supplemental Income Benefits
DFS-F2-DWC-49 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
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
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@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 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
(For use when billing for dates of services through July 7, 2010)
DFS-F5-DWC-9 Instructions Instructions for completion of the DWC-9
When submitted by Licensed Health Care Providers
(revised 3/1/2009)
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
(form revised 3/1/2009)
DFS-F5-DWC-10 Instructions Instructions for completion of the DWC-10
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 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 B Instructions For Hospitals Instructions for completion of the UB-04.
DFS-F5-DWC-90 C Instructions For Ambulatory Surgical Centers Instructions for completion of the UB-04.
(For use when billing dates of service on or after July 8, 2010).
DFS-F5-DWC-90 D Instructions For Home Health Agencies Instructions for completion of the UB-04.
(For use when billing dates of service on or after July 8, 2010).
DFS-F5-DWC-90 E Instructions For Nursing Home Facilities Instructions for completion of the UB-04.
(For use when billing dates of service on or after July 8, 2010).
Chapter 69L-9: Drug Testing Rule
NCCI Form 09-1 Application for Drug-Free Workplace Premium Credit Program
Chapter 69L-10: Claim For Reimbursement Against the Special Disability Trust Fund
DFS-F1-SDF-1 Proof of Claim
DFS-F1-SDF-2 Reimbursement Request
DFS-F1-SDF-6 Explanation of Benefits
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
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-29: Health Care Provider Certification
DFS Form 3160-0020 Health Care Provider Application for Certification
Tutorial [1.5MB PowerPoint] Health Care Provider Tutorial for Expert Medical Advisor certification
Chapter 69L-30: Expert Medical Advisors
DFS Form 3160-0021 Expert Medical Advisor Application and Contract For Certification
Tutorial [1.5MB PowerPoint] Health Care Provider Tutorial for Expert Medical Advisor certification
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)