To view the Workers' Compensation section of the Florida Statutes, see Chapter 440.
To view the Division of Workers' Compensation rules of the Florida Administrative Code, see Division 69L rules.
To view vocational rehabilitation rules and forms, visit the Vocational Rehabilitation site.
Click the tabs below to see forms related to each chapter of Division 69L (Worker's Compensation) of the Florida Administrative Code.
(All forms are in
PDF
format unless indicated otherwise.)
| 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. |
| Form (Click) | Form Number | Form Name |
|---|---|---|
 DFS (Form SI-1) |
DFS-F2-SI-1 | Application for Self-Insurance |
DFS (Form SI-1G) |
DFS-F2-SI-1G | Application for Governmental Self-Insurance |
DFS (Form SI-4F) |
DFS-F2-SI-4F | Self-Insurer’s Surety Bond for FSIGA Member |
DFS (Form SI-5) |
DFS-F2-SI-5 | Self-Insurer Payroll Report |
DFS (Form SI-6) |
DFS-F2-SI-6 | Self-Insurer’s Irrevocable Letter of Credit |
DFS (Form SI-8) |
DFS-F2-SI-8 | Self-Insurance Employer Application for Drug-Free Workplace Premium Credit Program |
DFS (Form SI-9) |
DFS-F2-SI-9 | Self-Insurance Certification of Workplace Safety Program Premium Credit |
DFS (Form SI-10) |
DFS-F2-SI-10 | Parental Guaranty and Corporate Resolution |
DFS (Form SI-11) |
DFS-F2-SI-11 | Indemnity Agreement |
DFS (Form SI-17) |
DFS-F2-SI-17 | Unit Statistical Report |
DFS (Form SI-19) |
DFS-F2-SI-19 | Certification of Servicing for Self-Insurers |
DFS (Form SI-20) |
DFS-F2-SI-20 | Report of Outstanding Workers’ Compensation Liabilities |
DFS (Form SI-22) |
DFS-F2-SI-22 | Qualified Servicing Entity Application |
DFS (Form SI-23) |
DFS-F2-SI-23 | Qualified Servicing Entity Annual Report |
DFS (Form SI-27) |
DFS-F2-SI-27 | Biographical Statement and Affidavit |
DFS (Form SI-GEP) |
DFS-F2-SI-GEP | Application for Governmental Self-Insurance Estimated Payroll |
| DWC 250 | Notice of Election to be Exempt |
| DWC 250 Instructions | Instructions for completing 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 |
| Request for Duplicate Exemption | Form used to request a duplicate certificate of election to be exempt. |
| 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@fldfs.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@fldfs.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). |
| NCCI Form 09-1 | Application for Drug-Free Workplace Premium Credit Program |
| DFS-F1-SDF-1 | Proof of Claim |
| DFS-F1-SDF-2 | Reimbursement Request |
| DFS-F1-SDF-6 | Explanation of Benefits |
| PW-1 | Preferred Worker Identification Card (Not available for download) |
| DFS-F1-PW-2 | Preferred Worker Reimbursement Request |
| PFB | Petition for Benefits can be obtained from the Division of Administrative Hearings website |
| EAO-1 | Request for Assistance |
| DFS Form 3160-0020 | Health Care Provider Application for Certification |
| Tutorial [1.5MB PowerPoint] | Health Care Provider Tutorial for Expert Medical Advisor certification |
| 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 |
| DFS Form 3160-0023 | Petition for Resolution of Reimbursement Dispute |
| DFS Form 3160-0024 | Carrier Response to Petition for Resolution of Reimbursement Dispute |
| 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 |
| 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) |
