Get Fl Oir Oir-b1-1809 2013-2026

The FL OIR OIR-B1-1809 form is a crucial document for health care providers seeking to certify eligibility for Personal Injury Protection benefits in Florida. This guide will provide step-by-step instructions to assist you in filling out the form accurately and completely.

Follow the steps to fill out the FL OIR OIR-B1-1809 form correctly.

1. Press the ‘Get Form’ button to access the FL OIR OIR-B1-1809 form online.
2. Begin by entering your name and title at the top of the form where indicated. Ensure that this information is printed or typed clearly.
3. In the section where you attest to providing medical benefits, select all applicable boxes to confirm the entity’s ownership as stated under Florida Statutes.
4. List the names, addresses, Florida practice license numbers, and ownership percentages of the licensed health care practitioners involved. Make sure the total ownership equals 100%.
5. If applicable, provide information for any family members who have an ownership interest in the clinic. Include their names, addresses, relationship to the practitioner, and ownership percentage.
6. Complete the section regarding hospital ownership by naming the hospital and explaining the ownership relationship.
7. For a health care clinic, ensure all accreditation details are filled in accurately, including the name of the accrediting agency and the date of current accreditation.
8. Provide the full name, license number, and contact number of the Medical Director if applicable.
9. Confirm that the health care clinic meets the necessary criteria regarding continuous licensing and medical specialties provided. Mark all medical specialties that apply.
10. Finally, sign the form as the Executive Officer or Medical Director. Include your title, printed name, license number, corporate name of the entity, and contact information.
11. If notarization is required, ensure that the section is completed, including the notary's signature and expiration date.
12. Review all entries for accuracy. You can then save changes, download, print, or share the completed form as necessary.

Complete your FL OIR OIR-B1-1809 form online today for efficient processing.