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Billing Forms

Last update
September 23, 2025

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.

DWC-25 - Workers’ Compensation Uniform Medical Treatment/Status Report Form

Type

Form Name

Description

Form (PDF)

DFS-F5-DWC-25

Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form, Effective June 25, 2006 (Rev. 1/31/2008)

Form (Interactive PDF)

DFS-F5-DWC-25

Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form, Effective June 25, 2006 (Rev. 1/31/2008)

Instructions

DFS-F5-DWC-25-A 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

DFS-F5-DWC-9-A Instructions

Instructions for completion of the DWC-9 when submitted by Licensed Health Care Providers (Rev. 01/01/2015)

Instructions

DFS-F5-DWC-9-B Instructions

Instructions for completion of the DWC-9 when submitted by Work Hardening and Pain Management Programs (Rev. 01/01/2015)

Instructions

DFS-F5-DWC-9-C 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

DFS-F5-DWC-10

Statement of Charges for Drugs and Medical Supplies Form (Rev. 01/01/2015)

Instructions

DFS-F5-DWC-10-A 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

DFS-F5-DWC-11-A 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

DFS-F5-DWC-90-A Instructions for Hospitals

Instructions for completion of the UB-04 (Rev. 12/08/2015)

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