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How to use or fill out completion instructions form dfs-f5-dwc-10 - Florida Department of Financial Services
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Click ‘Get Form’ to open it in the editor.
Begin with Section 1. Fill in the employee's name, social security number or division-assigned number, date of accident, date of birth, and gender by checking the appropriate box.
Continue with Section 2 for pharmaceutical products. Enter the NDC#, quantity, days supply, medication and strength, usual charge, RX#, DAW code, date filled, prescriber’s name and license number.
For medical equipment and supplies in Section 3, provide a description of the item(s), purchase or rental dates, usual charge, HCPCS code, quantity, and prescriber’s information.
Complete Section 4 by entering the pharmacy or medical supplier's name, FEIN#, physical address, remittance address if different, name of pharmacist or supplier and their license number.
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The provider must complete form DFS-F5-DWC-25 to request authorization for a medical treatment plan, to communicate to the carrier an injured employees medical status, to document the injured employees date of Maximum Medical Improvement (MMI date), and to document a Permanent Impairment Rating (PI Rating).
What does the Florida Department of Financial Services do?
The department fights financial fraud, waste and abuse in Florida; audits the states payments; and works to make governments finances transparent. Under the CFOs direction, the department also oversees the investment of funds held in the State Treasury.
What is a notice of determination from the Florida Department of Financial Services?
The Notice of Determination includes the Departments recommendation concerning the amount recommended and classification of a claim that was filed by you or someone on your behalf. If you agree with the amount recommended and the assigned class no further action on your part is needed.
Who is exempt from workers comp in FL?
Businesses that are exempt from workers comp in Florida include: Construction companies with no employees (including yourself by filing for an exemption) Businesses in other industries with three or fewer employees. Agricultural companies with five or fewer regular employees or 11 or fewer seasonal workers.
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