Florida Department of Financial Services Forms

This Form is used for public depositors in Florida to submit their annual report to the Chief Financial Officer.

This form is used for the disclosure of insurance premiums and certification for settlement agents in the state of Florida.

This document is used for submitting a proof of claim in the state of Florida. It is a form that allows individuals or entities to present their claim in legal proceedings.

This form is used for carriers in Florida to respond to a petition for resolution of a reimbursement dispute.

This Form is used for creating an inventory of property stored in a safe deposit box that is presumed to be unclaimed in the state of Florida.

This form is used for reporting sales of securities and how the proceeds from those sales are used in the state of Florida.

This Form is used for reporting unclaimed property in the estate of a deceased person in Florida.

This Form is used for reporting the medical treatment and status of injured workers in Florida's Workers' Compensation system. It helps to track the progress of the injured worker's medical treatment and determine their eligibility for benefits.

This Form is used for health care providers in Florida to submit health insurance claims. It provides instructions on how to accurately complete the form.

This Form is used for submitting health insurance claims related to work hardening and pain management programs in the state of Florida. It provides instructions on how to properly fill out the form and submit it to the appropriate insurance provider.

This type of document provides instructions for completing the CMS-1500 Health Insurance Claim Form specifically for Ambulatory Surgical Centers in Florida.

This form is used for reporting charges related to drugs, medical equipment, and supplies in the state of Florida.

This type of document is used by pharmacies and home medical equipment providers/suppliers in Florida to submit a Statement of Charges for Drugs and Medical Supplies. It provides instructions for completing the form.

This Form is used for completing and submitting an ADA Dental Claim Form in the state of Florida. It provides instructions on how to properly fill out the form to ensure accurate and timely processing of dental insurance claims.

This Form is used for billing purposes by hospitals in the state of Florida. It is known as the CMS-1450 Institutional Billing Form.

This document provides instructions for completing Form UB-04, also known as CMS-1450, which is the Institutional Billing Form used by Ambulatory Surgical Centers in Florida.

This document provides instructions for completing Form UB-04, also known as CMS-1450, which is used by Home Health Agencies in Florida for institutional billing.

This Form is used for institutional billing in nursing home facilities in Florida. It is also known as Form UB-04 or CMS-1450. The form is used to submit claims for reimbursement from Medicare, Medicaid, or other insurance providers for services provided to nursing home residents. The instructions provide guidance on how to complete the form accurately and submit it correctly.

This form is used for applying to the Drug-Free Workplace Premium Credit Program in Florida. Businesses can apply to receive a premium credit on their workers' compensation insurance policy by implementing and maintaining a drug-free workplace program.

This Form is used for requesting reimbursement in Florida.

This document is used to provide an explanation of benefits for individuals in Florida. It outlines the details of the healthcare services received and the corresponding costs, insurance coverage, and any additional information.

This form is used for requesting reimbursement for preferred workers in the state of Florida.

This Form is used for requesting screening in Florida.

This Form is used for requesting assistance in Florida.

This document is used for healthcare providers in Florida to apply for certification. It is called DFS Form 3160-0020 Health Care Provider Application for Certification.

This Form is used for applying for the certification of an expert medical advisor in the state of Florida.

This form is used for making payments regarding court-related fees, charges, costs, fines, and other monetary penalties in the state of Florida.

This form is used for submitting a request to add or update object codes in the Florida Department of Financial Services system.

This form is used to request a refund of FICA (Federal Insurance Contributions Act) taxes or contribute to the OPS (Other Personnel Services) FICA Alternative Retirement Plan in Florida.

This form is used for vendor direct deposit authorization in the state of Florida. It allows vendors to provide their bank account information for direct deposit of payments from the state.

This Form is used for requesting a duplicate warrant in the state of Florida.

This Form is used for attesting to forgery in the state of Florida. It is an affidavit that can be used as evidence in legal proceedings related to forged documents.

This Form is used for Wage Statement purposes in the state of Florida. It is a document that reports an employee's wages and other compensation.

This form is used for requesting wage loss or temporary partial benefits in the state of Florida.

This form is used for notifying the Department of Children and Families in Florida about any changes or actions related to your case.

This document is used to notify individuals in Florida of a denial.

This form is used for submitting a Claim Cost Report in the state of Florida. It is required to report and document the costs associated with a claim.

This Form is used for requesting information regarding Social Security Disability Benefits in Florida.

This Form is used for reporting employee earnings in the state of Florida. It helps employers keep track of their employees' wages and hours worked. The form includes information such as employee's name, social security number, and earnings for each pay period.