Reimbursement Request Form - Special Disability Trust Fund - Florida Page 3

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INSTRUCTIONS:
1. COMPLETE THIS FORM.
2. TOTAL AND ATTACH BILLS IN DATE OF SERVICE ORDER.
3. ATTACH AUDIT TAPE.
EMPLOYEE'S NAME
CLAIM NUMBER
DATE OF ACCIDENT
MEDICALS
NAME OF PROVIDER
DATE OF SERVICE
DATE PAID
AMOUNT PAID
TOTALS
Page _______________ of _______________
PAYMENT SCHEDULE B

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