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Statement Of Charges For Drugs And Medical Supplies Form. This is a Florida form and can be use in Workers Comp.
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Tags: Statement Of Charges For Drugs And Medical Supplies, DWC-10, Florida Workers Comp,
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 Drug Products - Complete sections 1, 2 & 4
For Supplies & Equipment - Complete sections 1, 3 & 4
SECTION I
1. EMPLOYEE'S NAME (FIRST, MIDDLE, LAST)
3. DATE OF ACCIDENT
2. EMPLOYEE'S SOCIAL SECURITY # OR DIVISION ASSIGNED #
4. EMPLOYEE'S DOB
5. GENDER
MALE
6. CLAIMS-HANDLING ENTITY INTERNAL FILE #
FEMALE
7. INSURER/CARRIER NAME & ADDRESS
8. EMPLOYER'S NAME & ADDRESS
SECTION 2
9. NDC# (5-4-2 format)
10. QUANTITY
14. RX #
new
13. USUAL CHARGE
$
17a. PRESCRIBER'S NAME
16. DATE FILLED
15. DAW CODE
17b. FL. DOH LICENSE #
11. DAYS
13. USUAL CHARGE
refill
10. QUANTITY
-
12. MEDICATION & STRENGTH
15. DAW CODE
14. RX #
$
17a. PRESCRIBER'S NAME
16. DATE FILLED
17b. FL. DOH LICENSE #
11. DAYS
13. USUAL CHARGE
refill
9. NDC# (5-4-2 format)
10. QUANTITY
14. RX #
new
12. MEDICATION & STRENGTH
-
9. NDC# (5-4-2 format)
new
PRESCRIPTION DRUGS
11. DAYS
12. MEDICATION & STRENGTH
15. DAW CODE
$
16. DATE FILLED
17b. FL. DOH LICENSE #
17a. PRESCRIBER'S NAME
refill
SECTION 3
MEDICAL EQUIPMENT & SUPPLIES
19a. PURCHASE DATE
23a. PRESCRIBER'S NAME
21. HCPCS CODE
22. QUANTITY
20. USUAL CHARGE
$
23a. PRESCRIBER'S NAME
18. DESCRIPTION OF MEDICAL EQUIPMENT OR SUPPLY
23b. FL DOH LICENSE #
19a. PURCHASE DATE
22. QUANTITY
$
19b. RENTAL DATE
21. HCPCS CODE
20. USUAL CHARGE
19b. RENTAL DATE
18. DESCRIPTION OF MEDICAL EQUIPMENT OR SUPPLY
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.)
28. NAME OF PHARMACIST OR MEDICAL SUPPLIER
29. PHARMACIST'S DOH LICENSE #/ MED. SUPPLIER'S LICENSE #
Check if Same
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. 3/1/2009
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