Get Oir B1 1809 Fillable

The Oir B1 1809 Fillable form is used for certifying eligibility for personal injury protection (PIP) benefits in Florida. This guide provides step-by-step instructions to help users fill out the form accurately and effectively.

Follow the steps to complete the Oir B1 1809 Fillable form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, print or type your name and title in the designated fields. Ensure that the information provided is clear and accurate.
3. In the following section, check all applicable boxes to indicate the entity providing medical benefits. This includes whether the entity is wholly owned by licensed health care practitioners or other specified entities.
4. List the names, addresses, and Florida practice license numbers of the licensed health care practitioners you identified in the previous step. Also, specify the percentage of ownership for each individual, ensuring that the total ownership adds up to 100%.
5. If applicable, provide the identification of family member owners by listing their names, addresses, relationships to the practitioner, and respective ownership percentages.
6. For entities owned by hospitals, provide the name of the hospital and a detailed explanation of the ownership relationship to the hospital.
7. Complete the section regarding health care clinics, including accreditation details and medical director information. Ensure all necessary conditions for eligibility are met.
8. Sign and print your name as the Executive Officer, Medical or Clinic Director in the designated area. Include the title, board or department of health license number, and the corporate name.
9. Provide the clinic's address, city, state, zip code, and phone number. Ensure all information is accurate and complete.
10. In the notarization section, have the document sworn and subscribed. Provide necessary identification details if required and ensure the notary's signature and commission expiration date are included.
11. Once all the fields have been completed, you can save the changes, download the filled form, print it, or share it as needed.

Start filling out your Oir B1 1809 Fillable form online today for a seamless experience!