Explanation Of Benefits {SDF-6} | Pdf Fpdf Doc Docx | Florida

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Explanation Of Benefits {SDF-6} | Pdf Fpdf Doc Docx | Florida

Explanation Of Benefits {SDF-6}

This is a Florida form that can be used for Workers Comp.

Alternate TextLast updated: 11/8/2010

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Description

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) American LegalNet, Inc. www.FormsWorkflow.com

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