Click the tabs below to see forms related to each chapter of Division 69L (Workers' Compensation) of the Florida Administrative Code.
| DFS-F2-DWC-1 DFS-F2-DWC-1 (Interactive) | First Report of Injury or Illness |
| DFS-F2-DWC-1a DFS-F2-DWC-1a (Interactive) | Wage Statement |
| DFS-F2-DWC-3 DFS-F2-DWC-3 (Interactive) | Request for Wage Loss/Temporary Partial Benefits |
| DFS-F2-DWC-4 DFS-F2-DWC-4 (Interactive) | Notice of Action/Change |
| DFS-F2-DWC-12 DFS-F2-DWC-12 (Interactive) | Notice of Denial |
| FS-F2-DWC-13 DFS-F2-DWC-13 (Interactive) | Claim Cost Report |
| DFS-F2-DWC-14 DFS-F2-DWC-14 (Interactive) | Request for Social Security Disability Benefit Information |
| DFS-F2-DWC-19 DFS-F2-DWC-19 (Interactive) | Employee Earnings Report |
| DFS-F2-DWC-30 DFS-F2-DWC-30 (Interactive) | Authorization and Request for Unemployment Compensation Information |
| DFS-F2-DWC-33 DFS-F2-DWC-33 (Interactive) | Permanent Total Off-Set Worksheet |
| DFS-F2-DWC-35 DFS-F2-DWC-35 (Interactive) | Permanent Total Supplemental Worksheet |
| DFS-F2-DWC-40 DFS-F2-DWC-40 (Interactive) | Statement of Quarterly Earnings for Supplemental Income Benefits |
| DFS-F2-DWC-49 DFS-F2-DWC-49 (Interactive) | Aggregate Claims Administration Change Report |
| DFS-F2-DWC-60 | Important Workers' Compensation Information for Florida's Workers |
| DFS-F2-DWC-61 | Informacion Importante De Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Trabajadores De La Florida |
| DFS-F2-DWC-65 | Important Workers' Compensation Information for Florida's Employers |
| DFS-F2-DWC-66 | Informacion Importante Del Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Empleadores De La Florida |
| DFS-F2-SI-1 | Application for Self Insurance |
| DFS-F2-SI-1G | Application for Governmental Self-Insurance |
| DFS-F2-SI-4F | Self-Insurer’s Surety Bond for FSIGA Member |
| DFS-F2-SI-5 | Self-Insurer Payroll Report |
| DFS-F2-SI-6 | Self-Insurer’s Irrevocable Letter of Credit |
| DFS-F2-SI-8 | Self-Insurance Employer Application for Drug-Free Workplace Premium Credit Program |
| DFS-F2-SI-9 | Self-Insurance Certification of Workplace Safety Program Premium Credit |
| DFS-F2-SI-10 | Parental Guaranty and Corporate Resolution |
| DFS-F2-SI-11 | Indemnity Agreement |
| DFS-F2-SI-17 | Unit Statistical Report |
| DFS-F2-SI-17 Excel Instructions | Form SI-17 Electronic Reporting Excel Training Manual |
| DFS-F2-SI-17 Text Instructions | Form SI-17 Electronic Reporting Text File Formatting Instructions |
| DFS-F2-SI-19 | Certification of Servicing for Self-Insurers |
| DFS-F2-SI-20 | Report of Outstanding Workers’ Compensation Liabilities |
| DFS-F2-SI-22 | Qualified Servicing Entity Application |
| DFS-F2-SI-23 | Qualified Servicing Entity Annual Report |
| DFS-F2-SI-27 | Biographical Statement and Affidavit |
| DFS-F2-SI-GEP | Application for Governmental Self-Insurance Estimated Payroll |
| DWC 250 | Notice of Election to be Exempt |
| DWC-250-R | Revocation of Election to be Exempt |
| DWC-251 | Notice of Election of Coverage |
| DWC-251-R | Revocation of Election of Coverage |
| DFS-F5-DWC-25 (PDF) | Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form, Effective June 25, 2006 (Rev. 1/31/2008) |
| DFS-F5-DWC-25 (Interactive PDF Format) | Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form, Effective June 25, 2006 (Rev. 1/31/2008) |
| DFS-F5-DWC-25 (Interactive Excel Format) Please see saving instructions to the right | Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form, Effective June 25, 2006 (Rev. 1/31/2008) To access the interactive form, right click the link. Select "save target as" to save the form in your personal files. Macros MUST be "enabled". Questions or difficulties encountered when using the form should be directed to the Workers' Compensation Medical Services Unit via email at Workers.MedService@myfloridacfo.com |
| DFS-F5-DWC-25 (Word Format) Please see saving instructions to the right. | Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form, Effective June 25, 2006 (Rev. 1/31/2008) To access the form in Word format, right click the link. Select "save target as" to save the form as a Word document in your personal files. After saving it as a Word file, you may also save it as a Word template. Questions or difficulties encountered when using the form should be directed to the Workers' Compensation Medical Services Unit via e-mail at Workers.MedService@myfloridacfo.com |
| DFS-F5-DWC-25-A Instructions | Instructions for completion of the DWC-25 (Rev. 01/01/2015) |
DFS-F5-DWC-9 (Rev. 02/12) form required to be submitted for dates of service on or after 02/18/2016
| DFS-F5-DWC-9 | Health Provider Claim Form/CMS-1500 - A copy of the DWC-9 can be obtained from the CMS website. |
| DFS-F5-DWC-9-A Instructions | Instructions for completion of the DWC-9 when submitted by Licensed Health Care Providers (Rev. 01/01/2015) |
| DFS-F5-DWC-9-B Instructions | Instructions for completion of the DWC-9 when submitted by Work Hardening and Pain Management Programs (Rev. 01/01/2015) |
| DFS-F5-DWC-9-C Instructions | Instructions for completion of the DWC-9 when submitted by Ambulatory Surgical Centers (For use when billing for dates of services through July 7, 2010) (Rev. 01/01/2015) |
DFS-F5-DWC-10 and DFS-F5-DWC-11 forms required to be submitted for dates of service on or after 02/18/2016.
| DFS-F5-DWC-10 | Statement of Charges for Drugs And Medical Supplies Form (Rev. 01/01/2015) |
| DFS-F5-DWC-10-A Instructions | Instructions for completion of the DWC-10 when submitted by pharmacies and home medical equipment providers/suppliers (Rev. 12/08/2015) |
| DFS-F5-DWC-11 | Dental Claim Form (Rev. 2012) - A copy of the DWC-11 can be obtained by contacting the American Dental Association. |
| DFS-F5-DWC-11-A Instructions | Instructions for completion of the DWC-11 for Dentists (Rev. 01/01/2015) |
DFS-F5-DWC-90 form required to be submitted by hospitals on and after 5/23/2007. The DFS-F5-DWC-90 is required to be used by Ambulatory Surgical Centers, Home Health Agencies, and Nursing Home Facilities on and after July 8, 2010.
| DFS-F5-DWC-90 | Institutional Billing Form (UB-04) - A copy of the DWC-90 can be obtained from the CMS website. |
| DFS-F5-DWC-90-A Instructions for Hospitals | Instructions for completion of the UB-04 (Rev. 12/08/2015) (For use when billing dates of service on or after 02/18/2016) |
| DFS-F5-DWC-90-B Instructions for Ambulatory Surgical Centers | Instructions for completion of the UB-04. (Rev. 12/08/2015) (For use when billing dates of service on or after 02/18/2016) |
| DFS-F5-DWC-90-C Instructions for Home Health Agencies | Instructions for completion of the UB-04. (Rev. 12/08/2015) (For use when billing dates of service on or after 02/18/2016) |
| DFS-F5-DWC-90-D Instructions for Nursing Home Facilities | Instructions for completion of the UB-04. (Rev. 12/08/2015) (For use when billing dates of service on or after 02/18/2016) |
| NCCI Form 09-01A | Application for Drug-Free Workplace Premium Credit Program |
