Form Dwc-10 - Statement Of Charges For Drugs And Medical Supplies

ADVERTISEMENT

FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
DIVISION OF WORKERS' COMPENSATION
BUREAU OF REHABILITATION AND MEDICAL SERVICES
2728 Centerview Drive, 100 Forrest Building
Tallahassee, Florida 32399-0664
STATEMENT OF CHARGES FOR DRUGS AND MEDICAL SUPPLIES
INSTRUCTIONS: PHARMACISTS AND MEDICAL SUPPLIERS - Complete this form in detail and mail it to the insurance carrier or self-insured employer.
PHARMACISTS: Complete sections 1, 2 & 4
MEDICAL SUPPLIERS: Complete sections 1, 3 & 4
SECTION 1
1. EMPLOYEE'S NAME
2. SOCIAL SECURITY NUMBER
3. DATE OF ACCIDENT
4. CARRIER NAME, ADDRESS & TELEPHONE NUMBER
5. EMPLOYER'S FIRM NAME AND ADDRESS
SECTION 2 - PRESCRIPTION DRUGS
6. Medication & Strength
7. Quantity
8. Days Supply
9. NDC
Manufacturer Item Package
15. Usual
(enter NDC# in boxes)
Charge
1
10. Rx #
New
12. Date Filled
13. Certification
14. Prescriber's DBPR License Number
Refill
6. Medication & Strength
7. Quantity
8. Days Supply
9. NDC
Manufacturer Item Package
15. Usual
(enter NDC# in boxes)
Charge
2
10. Rx #
New
12. Date Filled
13. Certification
14. Prescriber's DBPR License Number
Refill
6. Medication & Strength
7. Quantity
8. Days Supply
9. NDC
Manufacturer Item Package
15. Usual
(enter NDC# in boxes)
Charge
3
10. Rx #
New
12. Date Filled
13. Certification
14. Prescriber's DBPR License Number
Refill
SECTION 3 - MEDICAL SUPPLIES
16. Description of Medical Supply
17. Prescriber's DBPR License #
18. Purchase Date
19. Usual Charge
4
16. Description of Medical Supply
17. Prescriber's DBPR License #
18. Purchase Date
19. Usual Charge
5
16. Description of Medical Supply
17. Prescriber's DBPR License #
18. Purchase Date
19. Usual Charge
6
TOTAL CHARGES THIS STATEMENT
$
20.
SECTION 4
21. NAME AND ADDRESS OF PHARMACY OR MEDICAL SUPPLIER
22. DATE OF THIS STATEMENT
23. PHARMACIST DBPR
LICENSE NUMBER
24. PROVIDER FEDERAL EMPLOYER IDENTIFICATION NUMBER
25. SIGNATURE OF PHARMACIST OR MEDICAL SUPPLIER
FOR CARRIER USE
26. TOTAL REIMBURSED FROM SECTION 2
27. TOTAL REIMBURSED 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.
LES Form DWC-10 (09/01/94)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go