Form DFS-F3-DWC-23 "Request for Screening" - Florida

Form DFS-F3-DWC-23 is a Florida Department of Financial Services form also known as the "Request For Screening". The latest edition of the form was released in December 1, 2015 and is available for digital filing.

Download a PDF version of the Form DFS-F3-DWC-23 down below or find it on Florida Department of Financial Services Forms website.

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Download Form DFS-F3-DWC-23 "Request for Screening" - Florida

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D
F
S
EPARTMENT OF
INANCIAL
ERVICES
Division of Workers’ Compensation - Bureau of Employee Assistance
200 East Gaines Street, Tallahassee, Florida 32399-4225
REQUEST FOR SCREENING
Any authorized party filing a Request for Screening must complete blocks 1 through 12.
1. Employee Name
2. Social Security Number
3. Date of Accident
4. Address (include apartment number, city, state,
5. County
6. Telephone Number
& zip code)
This section to be completed by the injured employee:
I request a Department Screening and whatever services are determined appropriate to return me to
suitable gainful employment.
I am applying because:
I have talked with my employer and:
Employment may be available when I am released to work with permanent restrictions.
Employment within my restrictions has already been offered.
My employer has told me no work is available in my same job, modified job, or different job.
My employer has not told me any of the above, or I have not talked with my employer.
I certify that to the best of my knowledge and belief all of the statements contained herein are true,
correct, complete, and made in good faith.
Employee’s Signature
Date
7. Employer/Company Name
8. Employer/Company Address (include city, state & zip code)
9. Telephone Number
10. Carrier or SC/TPA Name
11. Carrier or SC/TPA Address (include city, state & zip code)
12. Telephone Number
I believe that the above-referenced employee is entitled to a Department screening for reemployment
services.
Employer or Carrier Signature/ Title
Date
 Check here if employer referral.
 Check here if carrier referral.
Form DFS-F3-DWC-23, Rev. 12/2015
Rule 69L-22.0011, F.A.C.
D
F
S
EPARTMENT OF
INANCIAL
ERVICES
Division of Workers’ Compensation - Bureau of Employee Assistance
200 East Gaines Street, Tallahassee, Florida 32399-4225
REQUEST FOR SCREENING
Any authorized party filing a Request for Screening must complete blocks 1 through 12.
1. Employee Name
2. Social Security Number
3. Date of Accident
4. Address (include apartment number, city, state,
5. County
6. Telephone Number
& zip code)
This section to be completed by the injured employee:
I request a Department Screening and whatever services are determined appropriate to return me to
suitable gainful employment.
I am applying because:
I have talked with my employer and:
Employment may be available when I am released to work with permanent restrictions.
Employment within my restrictions has already been offered.
My employer has told me no work is available in my same job, modified job, or different job.
My employer has not told me any of the above, or I have not talked with my employer.
I certify that to the best of my knowledge and belief all of the statements contained herein are true,
correct, complete, and made in good faith.
Employee’s Signature
Date
7. Employer/Company Name
8. Employer/Company Address (include city, state & zip code)
9. Telephone Number
10. Carrier or SC/TPA Name
11. Carrier or SC/TPA Address (include city, state & zip code)
12. Telephone Number
I believe that the above-referenced employee is entitled to a Department screening for reemployment
services.
Employer or Carrier Signature/ Title
Date
 Check here if employer referral.
 Check here if carrier referral.
Form DFS-F3-DWC-23, Rev. 12/2015
Rule 69L-22.0011, F.A.C.
DWC-23 Purpose and Use Statement
The collection of the social security number on this form is
specifically authorized by Section 440.185(2), Florida
Statutes. The social security number will be used as a unique
identifier in Division of Workers' Compensation database
systems for individuals who have claimed benefits under
Chapter 440, Florida Statutes. It will also be used to identify
information and documents in those database systems
regarding individuals who have claimed benefits under
Chapter 440, Florida Statutes, for internal agency tracking
purposes and for purposes of responding to both public
records requests and subpoenas that require production of
specified documents. The social security number may also be
used for any other purpose specifically required or authorized
by state or federal law.
Form DFS-F3-DWC-23, Rev. 12/2015
Rule 69L-22.0011, F.A.C.
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