Last updated: 10/1/2025
Statement Of Charges For Drugs And Medical Supplies {DWC-10}
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Description
Form DFS-F5-DWC-10 - STATEMENT OF CHARGES FOR DRUGS AND MEDICAL EQUIPMENT & SUPPLIES. The Florida Department of Financial Services (DFS) Division of Workers’ Compensation uses this form for pharmacists and medical suppliers to request reimbursement for prescription drugs, medical equipment, or supplies provided to injured workers. Depending on the type of service, suppliers must complete sections covering patient and claim details, drug information (including NDC numbers, dosage, and prescriber details), or equipment descriptions with HCPCS codes. Pharmacies and suppliers must also provide business identification details such as FEIN, addresses, and license numbers. Insurers or carriers use the form to calculate and record approved reimbursement amounts. False or misleading statements may result in felony charges under Florida law. Rule 69L-7.720, F.A.C. www.FormsWorkflow.com
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