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Get FL OIR-B1-1571 2004-2024

736 4 b Florida Statutes and may not be electronically furnished. Failure to furnish this form may result in non-payment of the claim. OIR-B1-1571 Pub. OFFICE OF INSURANCE REGULATION Bureau of Property Casualty Forms and Rates Standard Disclosure and Acknowledgement Form Personal Injury Protection - Initial Treatment or Service Provided The undersigned insured person or guardian of such person affirms 1. The services or treatment set forth below were actually rendered* This means that those services have already been provided* I have the right and the duty to confirm that the services have already been provided* I was not solicited by any person to seek any services from the medical provider of the services described above. The medical provider has explained the services to me for which payment is being claimed* 5. If I notify the insurer in writing of a billing error I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled my share would be at least 20 of the amount of the reduction up to 500. Insured Person patient receiving treatment or services or Guardian of Insured Person Name PRINT or TYPE Signature Date and also A. I have not solicited or caused the insured person who was involved in a motor vehicle accident to be solicited to make a claim for Personal Injury Protection benefits. B. The treatment or services rendered were explained to the insured person or his or her guardian sufficiently for that person to sign this form with informed consent. C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein* This means that each request for information has been responded to truthfully accurately and in a substantially complete manner. D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded unbundled or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627. 732 15 and 16 Florida Statutes or Section 627. 736 5 b 6 Florida Statutes. Licensed Medical Professional Rendering Treatment/Services or Medical Director if applicable Signature by his/ her own hand Any person who knowingly and with intent to injure defraud or deceive any insurer files a statement of Claim or an application containing any false incomplete or misleading information is guilty of a felony of the third degree per Section 817. 234 1 b Florida Statutes. Note The original of this form must be furnished to the insurer pursuant to Section 627. OFFICE OF INSURANCE REGULATION Bureau of Property Casualty Forms and Rates Standard Disclosure and Acknowledgement Form Personal Injury Protection - Initial Treatment or Service Provided The undersigned insured person or guardian of such person affirms 1. The services or treatment set forth below were actually rendered* This means that those services have already been provided* I have the right and the duty to confirm that the services have already been provided* I was not solicited by any person to seek any services from the medical provider of the services described above. .

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