Form DFS-F5-DWC-10 "Statement of Charges for Drugs and Medical Equipment & Supplies" - Florida

What Is Form DFS-F5-DWC-10?

This is a legal form that was released by the Florida Department of Financial Services - a government authority operating within Florida. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on January 1, 2015;
  • The latest edition provided by the Florida Department of Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form DFS-F5-DWC-10 by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

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Download Form DFS-F5-DWC-10 "Statement of Charges for Drugs and Medical Equipment & Supplies" - Florida

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FLORIDA DEPARTMENT OF FINANCIAL SERVICES - DIVISION OF WORKERS' COMPENSATION
STATEMENT OF CHARGES FOR DRUGS AND MEDICAL EQUIPMENT & SUPPLIES
Pharmacists & Medical Suppliers - Must complete this billing form in detail to file for reimbursement of services.
For Supplies & Equipment - Complete sections 1, 3 & 4For Drug Products - Complete sections 1, 2 & 4
SECTION I
1. EMPLOYEE'S NAME (FIRST, MIDDLE, LAST)
2. EMPLOYEE'S SOCIAL SECURITY # OR DIVISION ASSIGNED #
3. DATE OF ACCIDENT
4. EMPLOYEE'S DOB
5. GENDER
6. CLAIMS-HANDLING ENTITY INTERNAL FILE #
MALE
FEMALE
7. INSURER/CARRIER NAME & ADDRESS
8. EMPLOYER'S NAME & ADDRESS
SECTION 2 PRESCRIPTION DRUGS
9a. NDC NUMBER PRIMARY (5 4 2 format)
10. QUANTITY
11. DAYS
12. MEDICATION & STRENGTH
13. USUAL CHARGE
$
9b. NDC NUMBER SECONDARY (5 4 2 format)
14. RX #
15. DAW CODE
16. DATE FILLED
17a. PRESCRIBER'S NAME
17b. FL. DOH LICENSE #
new
refill
9a. NDC NUMBER PRIMARY (5 4 2 format)
10. QUANTITY
11. DAYS
12. MEDICATION & STRENGTH
13. USUAL CHARGE
$
9b. NDC NUMBER SECONDARY (5 4 2 format)
14. RX # new
15. DAW CODE
16. DATE FILLED
17a. PRESCRIBER'S NAME
17b. FL. DOH LICENSE #
new
refill
9a. NDC NUMBER PRIMARY (5 4 2 format)
10. QUANTITY
11. DAYS
12. MEDICATION & STRENGTH
13. USUAL CHARGE
$
9b. NDC NUMBER SECONDARY (5 4 2 format)
14. RX #
15. DAW CODE
16. DATE FILLED
17a. PRESCRIBER'S NAME
17b. FL. DOH LICENSE #
New
refill
SECTION 3 MEDICAL EQUIPMENT & SUPPLIES
18. DESCRIPTION OF MEDICAL EQUIPMENT OR SUPPLY
19a. PURCHASE DATE
20. USUAL CHARGE
19b. RENTAL DATE
$
21. HCPCS CODE
22. QUANTITY
23a. PRESCRIBER'S NAME
23b. FL DOH LICENSE #
18. DESCRIPTION OF MEDICAL EQUIPMENT OR SUPPLY
19a. PURCHASE DATE
20. USUAL CHARGE
19b. RENTAL DATE
$
21. HCPCS CODE
22. QUANTITY
23a. PRESCRIBER'S NAME
23b. FL DOH LICENSE #
SECTION 4
24. NAME OF PHARMACY OR MEDICAL SUPPLIER
25. REMITTANCE RECIPIENT'S FEIN #
26. PHYSICAL ADDRESS OF PHARMACY OR MEDICAL SUPPLIER
27. REMITTANCE ADDRESS (if different from Field 26.) Check if Same
28. NAME OF PHARMACIST OR MEDICAL SUPPLIER
29. PHARMACIST'S DOH LICENSE #/ MED. SUPPLIER'S LICENSE #
FOR INSURER/CARRIER USE
30. TOTAL REIMBURSEMENT FROM SECTION 2
31. TOTAL REIMBURSEMENT FROM SECTION 3
$
$
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY EMPLOYER OR EMPLOYEE, INSURANCE COMPANY, OR SELF-INSURED
PROGRAM, FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
Form DFS-F5-DWC-10 Rev. 1/1/2015
Rule 69L-7.720, F.A.C.
FLORIDA DEPARTMENT OF FINANCIAL SERVICES - DIVISION OF WORKERS' COMPENSATION
STATEMENT OF CHARGES FOR DRUGS AND MEDICAL EQUIPMENT & SUPPLIES
Pharmacists & Medical Suppliers - Must complete this billing form in detail to file for reimbursement of services.
For Supplies & Equipment - Complete sections 1, 3 & 4For Drug Products - Complete sections 1, 2 & 4
SECTION I
1. EMPLOYEE'S NAME (FIRST, MIDDLE, LAST)
2. EMPLOYEE'S SOCIAL SECURITY # OR DIVISION ASSIGNED #
3. DATE OF ACCIDENT
4. EMPLOYEE'S DOB
5. GENDER
6. CLAIMS-HANDLING ENTITY INTERNAL FILE #
MALE
FEMALE
7. INSURER/CARRIER NAME & ADDRESS
8. EMPLOYER'S NAME & ADDRESS
SECTION 2 PRESCRIPTION DRUGS
9a. NDC NUMBER PRIMARY (5 4 2 format)
10. QUANTITY
11. DAYS
12. MEDICATION & STRENGTH
13. USUAL CHARGE
$
9b. NDC NUMBER SECONDARY (5 4 2 format)
14. RX #
15. DAW CODE
16. DATE FILLED
17a. PRESCRIBER'S NAME
17b. FL. DOH LICENSE #
new
refill
9a. NDC NUMBER PRIMARY (5 4 2 format)
10. QUANTITY
11. DAYS
12. MEDICATION & STRENGTH
13. USUAL CHARGE
$
9b. NDC NUMBER SECONDARY (5 4 2 format)
14. RX # new
15. DAW CODE
16. DATE FILLED
17a. PRESCRIBER'S NAME
17b. FL. DOH LICENSE #
new
refill
9a. NDC NUMBER PRIMARY (5 4 2 format)
10. QUANTITY
11. DAYS
12. MEDICATION & STRENGTH
13. USUAL CHARGE
$
9b. NDC NUMBER SECONDARY (5 4 2 format)
14. RX #
15. DAW CODE
16. DATE FILLED
17a. PRESCRIBER'S NAME
17b. FL. DOH LICENSE #
New
refill
SECTION 3 MEDICAL EQUIPMENT & SUPPLIES
18. DESCRIPTION OF MEDICAL EQUIPMENT OR SUPPLY
19a. PURCHASE DATE
20. USUAL CHARGE
19b. RENTAL DATE
$
21. HCPCS CODE
22. QUANTITY
23a. PRESCRIBER'S NAME
23b. FL DOH LICENSE #
18. DESCRIPTION OF MEDICAL EQUIPMENT OR SUPPLY
19a. PURCHASE DATE
20. USUAL CHARGE
19b. RENTAL DATE
$
21. HCPCS CODE
22. QUANTITY
23a. PRESCRIBER'S NAME
23b. FL DOH LICENSE #
SECTION 4
24. NAME OF PHARMACY OR MEDICAL SUPPLIER
25. REMITTANCE RECIPIENT'S FEIN #
26. PHYSICAL ADDRESS OF PHARMACY OR MEDICAL SUPPLIER
27. REMITTANCE ADDRESS (if different from Field 26.) Check if Same
28. NAME OF PHARMACIST OR MEDICAL SUPPLIER
29. PHARMACIST'S DOH LICENSE #/ MED. SUPPLIER'S LICENSE #
FOR INSURER/CARRIER USE
30. TOTAL REIMBURSEMENT FROM SECTION 2
31. TOTAL REIMBURSEMENT FROM SECTION 3
$
$
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY EMPLOYER OR EMPLOYEE, INSURANCE COMPANY, OR SELF-INSURED
PROGRAM, FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
Form DFS-F5-DWC-10 Rev. 1/1/2015
Rule 69L-7.720, F.A.C.