Florida workers’ compensation providers must use official Division of Workers’ Compensation (DWC) forms for medical billing, claims reporting, and reimbursement compliance.
Below are the required Florida workers’ comp forms with links (when applicable) to the official PDFs and instructions for accurate completion.
Billing Form Requirements
To ensure compliance, medical bills must be submitted on the correct form, depending on the type of service provided.
Services |
Forms |
|
Physician Services Pathology / Laboratory |
Form DFS-F5-DWC-9-A (CMS-1500 for Physicians) |
|
Facility – Outpatient Facility – Inpatient |
UB-04 |
Pharmacy |
NCPDP |
Dental |
|
Statement of Charges for Drugs and Medical Equipment & Supplies Form |
DWC-25 - Workers’ Compensation Uniform Medical Treatment/Status Report Form
Type |
Form Name |
Description |
Form (PDF) |
Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form, Effective June 25, 2006 (Rev. 1/31/2008) |
|
Form (Interactive PDF) |
Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form, Effective June 25, 2006 (Rev. 1/31/2008) |
|
Instructions |
Instructions for completion of the DWC-25 (Rev. 01/01/2015) |
DWC-9 - Health Provider Claims Form/CMS-1500
Type |
Form Name |
Description |
Form |
DFS-F5-DWC-9 |
Health Provider Claims Form/CMS-1500 - A copy of the DWC-9 can be obtained from the CMS website. |
Instructions |
Instructions for completion of the DWC-9 when submitted by Licensed Health Care Providers (Rev. 01/01/2015) |
|
Instructions |
Instructions for completion of the DWC-9 when submitted by Work Hardening and Pain Management Programs (Rev. 01/01/2015) |
|
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) (Rev. 01/01/2015) |
DWC-10 - Statement of Charges for Drugs and Medical Supplies Form
Type |
Form Name |
Description |
Form |
Statement of Charges for Drugs and Medical Supplies Form (Rev. 01/01/2015) |
|
Instructions |
Instructions for completion of the DWC-10 when submitted by pharmacies and home medical equipment providers/suppliers (Rev. 12/08/2015) |
DWC-11 - Dental Claim Form
Type |
Form Name |
Description |
Form |
DFS-F5-DWC-11 |
Dental Claim Form (Rev. 2012) - A copy of the DWC-11 can be obtained by contacting the American Dental Association. |
Instructions |
Instructions for completion of the DWC-11 for Dentists (Rev. 01/01/2015) |
DWC-90 - Institutional Billing Form
Type |
Form Name |
Description |
Form |
DFS-F5-DWC-90 |
Institutional Billing Form (UB-04) - A copy of the DWC-90 can be obtained from the CMS website. |
Instructions - Hospitals |
Instructions for completion of the UB-04 (Rev. 12/08/2015) |
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