Free DFS-F1-SDF-2 - Florida

REIMBURSEMENT REQUEST FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION OFFICE OF SPECIAL DISABILITY TRUST FUND
200 East Gaines Street Tallahassee, Florida 32399-4223

SDTF RECEIVED DATE

Note: This report must be signed by the employer or his duly authorized agent or carrier. Supporting records are subject to audit by the Division of Workers' Compensation. The signed original and one copy must be filed with the Fund by the employer or carrier requesting reimbursement. PLEASE PRINT OR TYPE
EMPLOYEE NAME SDTF CLAIM NUMBER DATE OF ACCIDENT

NAME OF EMPLOYER

CARRIER CODE #

SERVICE CO/TPA CODE #

BASE COMPENSATION RATE

COMPENSATION RATE COMPENSATION RATE WITH S/S OFFSET $

IMPAIRMENT RATING %

MMI DATE

PT DATE

PERMANENT IMPAIRMENT (D/A Before 1/1/94) PI DATE IMPAIRMENT INCOME (D/A On or After 1/1/94) From WAGE LOSS To

TEMPORARY TOTAL From TEMPORARY PARTIAL From MEDICAL (PHYSICIAN FEES) From HOSPITAL To

To

From To SUPPLEMENTAL INCOME BENEFITS (D/A On or After 1/1/94) From PERMANENT TOTAL To

To

From To PERMANENT TOTAL SUPPLEMENTAL From To LUMP SUM SETTLEMENT (JPO) Date DEATH From TOTAL PERMANENT COMPENSATION To

From To DRUGS, BRACES, PROSTHESIS, OTHER SUPPLIES From To TRAVEL / MILEAGE From ATTENDANT CARE From FUTURE MEDS To

To

TOTAL MEDICAL AND TEMPORARY COMPENSATION TOTAL PERMANENT, TEMPORARY AND MEDICAL BENEFITS TOTAL AMOUNT REIMBURSEMENT REQUESTED $

PERIOD FOR WHICH REIMBURSEMENT IS REQUESTED From To TOTAL REIMBURSED PRIOR TO THIS REQUEST $ THIRD PARTY RECOVERIES $ NAME AND ADDRESS OF PAYEE:

CALCULATIONS/FORMULA

PAYEE'S FEDERAL TAX ID# ______________________________________ MAIL CHECK TO: COMMENTS

ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY EMPLOYER OR EMPLOYEE, INSURANCE COMPANY, SELF-INSURED PROGRAM, FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE. I HEREBY CERTIFY THAT ALL OF THE SUMS LISTED ON THIS FORM HAVE BEEN PAID, AND I FURTHER CERTIFY THAT EXPENDITURES FOR ATTORNEYS FEES, PENALTIES AND INTEREST, DEPOSITION AND COURT COSTS HAVE NOT BEEN INCLUDED ON THIS PREPARER'S SIGNATURE: SIGNED BY: CARRIER NAME, ADDRESS & TELEPHONE #

PREPARER'S TYPED NAME:

TITLE:

PREPARER'S TELEPHONE #:

DATE:

FORM DFS-F1-SDF-2 (1/31/2008)

INSTRUCTIONS:

ATTACH APPROPRIATE DOCUMENTATION 1. TT - DWC-4 2. TP - DWC-3 3. WAGE LOSS - DWC-3's 4. PTD PAYSHEET 5. DEATH PAYSHEET 6. PI - DRAFT COPIES AND DWC-4's NOTE: DWC-3's AND DWC-4's MUST BE FULLY COMPLETED WITH SIGNATURE, DATE PAID AND AMOUNT PAID. EMPLOYEE'S NAME

CLAIM NUMBER

DATE OF ACCIDENT

PERIOD

COMPENSATION RATE

TEMPORARY TOTAL

TEMPORARY PARTIAL

WAGE LOSS

PERMANENT TOTAL

DEATH BENEFITS

PERMANENT IMPAIRMENT

TOTALS

Page _______________ of _______________ PAYMENT SCHEDULE A

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

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

HOSPITAL
NAME OF PROVIDER DATE OF SERVICE DATE PAID AMOUNT PAID

TOTALS Page _______________ of _______________ PAYMENT SCHEDULE C

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

RX AND MILEAGE
NAME OF PROVIDER DATE OF SERVICE DATE PAID AMOUNT PAID

TOTALS Page _______________ of _______________ PAYMENT SCHEDULE D

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

MISCELLANEOUS (PLEASE SPECIFY)
NAME OF PROVIDER DATE OF SERVICE DATE PAID AMOUNT PAID

TOTALS Page _______________ of _______________ PAYMENT SCHEDULE E