Statement Of Charges For Drugs And Medical Supplies {DWC-10}

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) 2. EMPLOYEE'S SOCIAL SECURITY # OR DIVISION ASSIGNED # 3. DATE OF ACCIDENT 4. EMPLOYEE'S DOB 5. GENDER MALE FEMALE 6. CLAIMS-HANDLING ENTITY INTERNAL FILE # 7. INSURER/CARRIER NAME & ADDRESS 8. EMPLOYER'S NAME & ADDRESS SECTION 2 9. NDC# (5-4-2 format) 10. QUANTITY 11. DAYS PRESCRIPTION DRUGS 12. MEDICATION & STRENGTH 13. USUAL CHARGE 14. RX # 15. DAW CODE 16. DATE FILLED 17a. PRESCRIBER'S NAME $ 17b. FL. DOH LICENSE # new refill 10. QUANTITY 11. DAYS 12. MEDICATION & STRENGTH 13. USUAL CHARGE 9. NDC# (5-4-2 format) 14. RX # 15. DAW CODE 16. DATE FILLED 17a. PRESCRIBER'S NAME $ 17b. FL. DOH LICENSE # new refill 10. QUANTITY 11. DAYS 12. MEDICATION & STRENGTH 13. USUAL CHARGE 9. NDC# (5-4-2 format) 14. RX # 15. DAW CODE 16. DATE FILLED 17a. PRESCRIBER'S NAME $ 17b. FL. DOH LICENSE # new refill SECTION 3 18. DESCRIPTION OF MEDICAL EQUIPMENT OR SUPPLY MEDICAL EQUIPMENT & SUPPLIES 19a. PURCHASE DATE 19b. RENTAL DATE 20. USUAL CHARGE $ 23b. FL DOH LICENSE # 21. HCPCS CODE 22. QUANTITY 23a. PRESCRIBER'S NAME 18. DESCRIPTION OF MEDICAL EQUIPMENT OR SUPPLY 19a. PURCHASE DATE 19b. RENTAL DATE 20. USUAL CHARGE $ 23b. FL DOH LICENSE # 21. HCPCS CODE 22. QUANTITY 23a. PRESCRIBER'S NAME 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. 3/1/2009 American LegalNet, Inc. www.FormsWorkFlow.com