Free DFS-F1-SDF-6 - Florida


File Size: 7.6 kB
Pages: 1
Date: January 31, 2008
File Format: PDF
State: Florida
Category: Workers Compensation
Word Count: 60 Words, 481 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.fldfs.com/wc/pdf/DFS-F1-SDF-6.pdf

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Preview DFS-F1-SDF-6
SDF-6 Explanation of Benefits

Claimant Name: SDTF Claim No.: Date of Accident: Employer: Provider I.D.: Provider Name: Provider Address:

Insurer Name: Insurer Code No.: Insurer FEIN:

Diagnosis:

1) 2)

3) 4)

Service Dates: From To

Procedure Diag Codes Description Code

Provider Charges

Recommended EOB Reduction Payment Code

Total Charged: Reductions: ********************* Total Payable: ********************* Explanation of Benefits:

Form DFS-F1-SDF-6 (Rev. 1/31/2008)