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)