Health Care Provider Violation Referral Form {DWC-2000}

Form DFS-F6-DWC-2000 - HEALTH CARE PROVIDER VIOLATION REFERRAL FORM. This Florida Department of Financial Services (DFS) form allows parties to report alleged violations by health care providers under the state’s workers’ compensation system. It is used to refer potential violations such as collecting payment directly from an injured worker, failing to follow Standards of Care, overutilization of services, failing to provide required medical records, failing to refund improper reimbursements, or improper billing under Rule 69L-7.602, F.A.C.. Each violation type requires a separate referral form with supporting documentation, such as Explanation of Bill Review (EOBR), peer review reports, correspondence, collection letters, or medical bills. The completed form and attachments must be mailed to DFS’s Division of Workers’ Compensation, Office of Medical Services, in Tallahassee. Rule 69L-34.003, F.A.C. www.FormsWorkflow.com