Forms and Publications


These forms are included in your injured worker packet.

False or Fraudulent Claim Warning
Florida State Law requires that you carefully read, sign and return this form to Summit.

Florida Statement of Injured
Please complete this form with the details of your injury and return it to Summit.

Medical Release
You must sign this form, have it witnessed and return it to Summit in order for us to process your compensation.

Statement of Charges for Drugs and Medical Supplies
If you paid for any injury-related medical supplies or prescriptions prior to receiving your prescription drug ID card, you may use this form to request reimbursement. Ask your pharmacist to complete the form, and return it with a copy of your paid receipt to Summit.

Formal Grievance Form
You may use this form to submit a formal grievance under the terms of Summit’s Managed Care Arrangement.

First Report of Injury or Illness
This form is used to report a work-related injury or illness to Summit. The copy in your injured worker packet includes the information given to Summit when your injury was reported to us. Keep that copy for your records.

Summit Workers’ Compensation Managed Care Program Handbook   (Spanish)
This brochure is mailed with your injured worker packet. It summarizes the claims process, and includes much of the same information you will find on this website.

Workers' Compensation Initial Care Satisfaction Survey
This survey is an important tool that we use to evaluate the patient care provided to you through our medical network. Please complete it and return it to Summit when requested.

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