Form Dwc-21 - Reemployment Services Reporting Form - Florida Department Of Labor

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FLORIDA DEPARTMENT OF LABOR & EMPLOYMENT SECURITY
FOR CARRIER'S DATE STAMP
SENT TO DIVISION
DIVISION OF WORKERS' COMPENSATION
BUREAU OF REHABILITATION & MEDICAL SERVICES
2728 Centerview Drive, 100 Forrest Building
Tallahassee, Florida 32399-0664
REEMPLOYMENT SERVICES REPORTING FORM
1. NAME
2. SOCIAL SECURITY NUMBER
3. DATE OF ACCIDENT
4. DATE OF REFERRAL
5. TELEPHONE NUMBER
6. A) CARRIER/TPA ADDRESS
7. A) REMIT TO
B) ADDRESS
C) CITY
D) STATE
B) ZIP CODE
E) ZIP CODE
C) SC/TPA CODE
FEIN #
F) TELEPHONE NUMBER
G) PROVIDER FEIN
D) CARRIER CODE
FEIN #
8. BILLING TYPE:
9. BILLING DATE
INITIAL
INTERIM
FINAL
10. PROVIDER STATUS:
INDEPENDENT
FACILITY
IN-HOUSE
11. COUNTY OF SERVICE
SERVICE COMPANY AFFILIATED
WC
DVR COUNSELING
12. A) PROVIDER NAME
B) PROVIDER NUMBER
13. A) FACILITY/COMPANY NAME
B) FACILITY/COMPANY NUMBER
14. CLOSURE DATE
15. CLOSURE CODE
16. RETURN TO WORK DATE
17. STARTING WEEKLY WAGE
BILLING INFORMATION
23. AMOUNT
18. DATE
19. REEMPLOYMENT SERVICE
20. UNITS
21. CHARGE
22. TOTAL
A) CODE
B) MOC
C) DESCRIPTION
OF SERVICE
OF SERVICE
PER UNIT
CHARGE
REIMBURSED
24. DATE RECEIVED
25. DATE REIMBURSED
26.
27.
TOTALS
$
$
LES Form DWC-21 (08/30/95)

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