Get Form Dfs-f5-dwc-11 - Florida's Department Of Financial Services

Filling out Form DFS-F5-DWC-11 correctly is crucial for ensuring that dental claims are processed efficiently by Florida's Department of Financial Services. This guide offers clear, step-by-step instructions to help users accurately complete each section of the form online.

Follow the steps to fill out the form accurately.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. In the header information section (Fields 1 and 2), mark ‘x’ in the box for ‘Statement of Actual Services’ and optionally enter the preauthorization number if applicable.
3. For the insurance company/dental benefits plan information (Field 3), provide the name, address, and zip code of the workers’ compensation insurer or carrier.
4. Skip Fields 4 through 11 in the other coverage section as no entries are required.
5. In the policyholder/subscriber information section (Fields 12-17), fill in the name, address, and zip code of the employer of the injured employee. No entries are required for other fields.
6. In the patient information section (Fields 18-23), enter the injured employee's last name, first name, middle initial, date of birth, and gender, marking ‘M’ for male or ‘F’ for female. Patient ID is optional.
7. In the record of services provided section (Fields 24-33), enter the date of service, tooth numbers, procedure codes, descriptions, and fees. Ensure to total all charges accurately.
8. Mark missing teeth in Field 34 and provide remarks about any unusual services in Field 35.
9. In the authorizations section (Fields 36 and 37), ensure the injured employee or their representative has signed and dated appropriately, or note if the signature is on file.
10. In the ancillary claim/treatment information section (Fields 38-47), indicate the place of treatment, number of enclosures, and relevant treatment details, including date of accident.
11. Fill in the billing dentist or dental entity information (Fields 48-52A) including the name, address, and payment identification number. Only the identification number needs to be filled out.
12. Enter the treating dentist and treatment location information (Fields 53-58), ensuring to match the dentist’s name and license number as required.
13. After completing all sections, review your entries carefully, then save your changes, download, print, or share the completed form as necessary.

Start filling out your Form DFS-F5-DWC-11 online today to ensure your claim is processed without delays!