Florida Workers’ Compensation Forms – From the Claimant’s Perspective

maze.jpgInjured Florida workers who seek workers’ compensation medical or indemnity (wage loss) benefits will see and be required to complete a variety of forms. It is important for Claimants to understand and complete the forms properly. Being wrong can lead to serious consequences including the denial of benefits and criminal prosecution for insurance fraud.

We represent injured workers. This blog will discuss the forms from that perspective.

First Report of Injury or Illness (DFS-F2-DWC-1)
This form contains basic factual information, such as a brief description of the accident, contact information of the employee, employer, and workers’ compensation insurance company, wage information, and is submitted to the workers’ compensation carrier and the Division of Administrative Hearings (DOAH), the state agency responsible for administering workers’ compensation cases. It is to be completed as soon after the accident as possible and signed by the employer and, when possible, the injured worker. Injured workers should review the form carefully, especially with regard to the description of the accident, before signing, and obtain an executed copy at that time.
Rule 69L-3.004
Specific Authority: 440.185(2), (5), (9), 440.19, 440.35, 449.591 FS. Law Implemented 440.185(2), (3), (5), 440.207(2), 440.35 FS. History-New 8-30-79, Amended 12-23-80, 11-5-81, 6-12-84, Formerly 38F-3.04, Amended 1-1-87, 4-11-90, 1-30-91, 11-8-94, Formerly 38F-3.004, 4L-3.004, Amended 1-10-05.

Wage Statement (DFS-F2-DWC-1a)
This form is not prepared or signed by the injured worker. It contains the employee’s wage information in order to calculate his/her average weekly wage (AWW). If applicable, the 13 week period immediately preceding the accident will be used to derive the AWW. Otherwise, a series of formulas will be considered, including the earnings of similar employees with the requisite 13 weeks of earnings and the contract of hire. Where the numbers provided in the form are questionable as to their accuracy, they can be cross-checked by payroll records and paycheck stubs. Frequent battles are fought over the correct AWW. Fringe benefits (e.g., health insurance) may also figure into the calculation.
Rule 69L-3.0046
Specific Authority: 440.14, 440.185(5), 440.591 FS. Law Implemented 440.12(2), 440.185(5), (9) FS. History-New 1-10-05, Amended 3-16-09.

Fraud Statement
Upon request from the employer, the employee must sign and return a form containing the language located in Florida Statute Section 440.105(7). The ostensible purpose of the form is to inform the claimant that knowingly and intentionally filing a false claim may constitute insurance fraud. We view it as a not so subtle message from employers and insurance carriers for employees to think twice about seeking workers’ compensation benefits, even entirely legitimate claims. Nevertheless, unless the form is signed and returned, benefits can be suspended. The employer/carrier are limited to one form per year.
Rule 69L-3.0047
Specific Authority: Specific Authority 440.105(7), 440.591 FS. Law Implemented 440.105(7) FS. History-New 1-10-05.

Medical Authorization and Description of Incident
Workers’ compensation insurance carriers sometimes ask claimants to execute these forms. This particular Description of Incident form is different than the one contained in the First Report of Injury or Illness.

The Patient/Physician privilege of confidentiality is one of the most sacred in American jurisprudence. Sadly, the Florida Legislature has decided that injured workers lose this privilege in exchange for receiving workers’ compensation benefits. Pursuant to 440.13(4)(c), “An employee who reports an injury or illness alleged to be work-related waives any physician-patient privilege with respect to any condition or complaint reasonably related to the condition for which the employee claims compensation.” Accordingly, the only time an employee must execute a carrier’s medical authorization form is when “medical records, reports, and information of an injured employee are sought from health care providers who are not subject to the jurisdiction of the state.” 440.13(4)(c).

There is nothing in the law that requires the claimant to complete this Description of Injury form. We view the form as an effort by the employer/carrier to obtain evidence on which a denial of benefits or a claim for insurance fraud can be based. We do not allow our clients to complete this form.

We do require our clients to sign our firm’s medical authorization form. This allows us to obtain their medical records from all providers.

Mileage Reimbursement
The carrier should send this form to the claimant to be completed and returned. Properly completed, the carrier should reimburse the claimant for travel expenses to and from authorized medical appointments, including physical therapy. The information provided in the form includes dates of service and round trip mileage. Effective July 1, 2011, the Internal Revenue Service’s deductible rate is 55.5 cents per mile.

It is important to be accurate with the information provided. Carriers will examine the information closely for misrepresentations, hoping to find even the slightest error on which to base a denial of benefits. Claimants should not fudge the numbers to make a few dollars.

Upon request, carriers will provide transportation.

Uniform Medical Treatment/Status Reporting Form (DFS-F5-DWC-25)
This form is completed by the medical provider after each appointment and furnished to the carrier. It contains the providers opinions regarding such factors as medical findings, whether the cause is work related or not, the treatment plan, functional capacities, and maximum medical improvement. The claimant should obtain a copy before leaving the medical provider’s office and give it to his or her attorney.

Notice of Denial (DFS-F2-DWC-12)
This form is completed by the insurance company and filed with DOAH. The carrier uses it to explain why it is denying specific benefits. The information can be disputed by the claimant.
Rule 69L-3.012
Specific Authority: 440.185(5), 440.20(3), 440.591 FS. Law Implemented 440.12(2), 440.14, 440.192(8), 440.20(2), (4), (9), (15)(f), 440.207(2) FS. History-New 10-30-79, Amended 11-5-81, 5-30-82, 6-12-84, Formerly 38F-3.12, Amended 4-11-90, 1-30-91, 11-8-94, Formerly 38F-3.012, 4L-3.012, Amended 1-10-05.

Notice of Action/Change (DFS-F2-DWC-4)
This form is completed by the insurance carrier. It contains claim status information pertinent to the provision of benefits. The information may not be correct and is subject to dispute by the claimant.
Rule 69L-3.0091
Specific Authority: 440.185, 440.20(3), 440.591 FS. Law Implemented 440.15(3)(d)2., 440.185, 440.20, 440.207(2), 440.51(8), (9) FS. History- New 1-30-91, Amended 11-8-94, Formerly 38F-3.0091, 4L-3.0091, Amended 1-10-05.

Request for Social Security Disability Benefit Information (DFS-F2-DWC-14)
This form authorizes the Social Security Administration to provide the carrier with Social Security Disability (SSD) information with regard to the claimant. Pursuant to F.S. 440.15(9)(c), the claimant must sign and return the authorization form to the carrier within 21 days after the date of receipt. A failure to do so, even if the claimant has not applied for SSD, could lead to a suspension of workers’ compensation benefits.

SSD information is relevant to workers’ compensation cases for a variety of reasons, including the offset of payments and disability status.

Authorization and Request for Unemployment Compensation Information (DFS-F2-DWC-30)
This form, like the Request for Social Security Disability Benefit Information, must be signed by the claimant and returned to the carrier. It authorizes the Agency for Workforce Administration, which administers unemployment compensation claims, to provide the carrier with information. As with every document that requires claimant input, special effort must be made to keep the information accurate.

UC information is relevant to workers’ compensation cases for offset and disability status reasons.

Employee Earnings Report (DFS-F2-DWC-19)
This form requires the claimant to provide a significant amount of information pertaining to employment status and the receipt of money. Failure to complete and return it [to the carrier] on time (within 21 days of receipt) and accurately can have serious negative consequences for the claimant. We assist our clients in completing this form.

Job Search Form
Completion of a job search form used to be a legal requirement to receive workers’ compensation wage loss benefits. This is no longer the case. However, it is still a good idea for claimants to keep a log. Current law continues to require a connection between the injury and wage loss. The log is a step in making the connection. Additionally, an exhaustive job search is one of the best ways of proving that a claimant is permanently and totally disabled. We encourage our clients to record their job search efforts. The Agency for Workforce Administration requires the regular completion of a job search form to maintain entitlement to unemployment compensation.

The form provided here is just a sample that can be modified for the circumstances.

Petition for Benefits
This is a legal pleading that is prepared by the claimant’s attorney and signed by both the lawyer and the claimant. As the name implies, it contains a list of benefits being sought by the claimant from the employer/insurance carrier. If the parties are unable to reach agreement with regard to the claimed benefits, the issues will be decided by a Judge of Compensation Claims after an evidentiary hearing. Any misrepresentations in this document can result in the serious consequences previously mentioned.

Response to Petition for Benefits
This document, which is prepared and filed by the carrier in response to the claimant’s Petition for Benefits, sets forth the carrier’s position with regard to the provision of benefits the claimant is seeking.

As this list demonstrates, the Florida’s workers’ compensation system can be a terrain full of land minds for the uninitiated. To avoid the dangers and to guarantee greater success, we encourage injured workers to seek the counsel of experienced workers’ compensation lawyers sooner rather than later.

Contact us toll-free at 866-785-GALE or by email to learn your rights.

Jeffrey P. Gale, P.A. is a South Florida based law firm committed to the judicial system and to representing and obtaining justice for individuals – the poor, the injured, the forgotten, the voiceless, the defenseless and the damned, and to protecting the rights of such people from corporate and government oppression. We do not represent government, corporations or large business interests.

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