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DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION FORM DFSF5DWC90A (UB04) COMPLETION INSTRUCTIONS FOR HOSPITALS SHALL COMPLETE THE DFSF5DWC90 (UB04) ACCORDING TO THESE INSTRUCTIONS
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2015 2014 Florida UB ICD F5 DFS DWC 69L INSURER DWC90 NUBC YYYY NPI ZZ99999999999 HCPCS 74a 9ICD 0ICD 67A ECI HIPPS DCN UB04 modifier 70a Outof FFemale BIRTHDATE 69L7 72a UUnknown MMale

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