The Florida Division of Workers’ Compensation has enacted a new rule that obligates medical providers to use new billing forms with required fields (Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule, 69L-7.602). Starting June 25, 2007, outdated forms or forms that are submitted to Summit without the required fields completed may be returned to you.

Click the links below to view samples of these forms that have the required fields highlighted. (Note that some forms are known by a few different names.) These sample forms are provided for your reference only and should not be downloaded for use.

• DWC-09/HCFA 1500/CMS 1500 (Health Insurance Claim Form)
• DWC-10 (Statement of Charges for Drugs and Medical Equipment & Supplies)
• DWC-90/UB-04/CMS-1450 (Uniform Bill)
• DWC-11 (ADA Dental Form)

Please call the state’s Office of Medical Services Help Desk at (850) 413-1613 if you have any questions.

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