CFO Jimmy's Patronis' Seal

Billing Form Completion Instructions

Form DFS-F5-DWC-9-ACompletion Instructions for Physicians and Recognized Practitioners, Rev. 01/01/2015
Form DFS-F5-DWC-9-BCompletion Instructions for Work Hardening and Pain Management Programs, Rev. 01/01/2015
Form DFS-F5-DWC-9-CCompletion Instructions for Ambulatory Surgical Centers, Rev. 01/01/2015 (only for dates of services prior to July 8, 2010)
Form DFS-F5-DWC-10-ACompletion Instructions for Pharmacies and Home Medical Equipment Providers/Suppliers, Rev. 12/08/2015
Form DFS-F5-DWC-11-ACompletion Instructions for Dentists, Rev. 01/01/2015
Form DFS-F5-DWC-90-A (UB-04)Completion Instructions for Hospitals, Rev. 12/08/2015
Form DFS-F5-DWC-90-B (UB-04) (for dates of service on and after 07/08/2010)Completion Instructions for Ambulatory Surgical Centers, Rev. 12/08/2015
Form DFS-F5-DWC-90-C (UB-04)Completion Instructions for Home Health Agencies, Rev. 12/08/2015
Form DFS-F5-DWC-90-D (UB-04)Completion Instructions for Nursing Home Facilities, Rev. 12/08/2015