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 w....
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How to fill out the FL OIR-B1-1571 online
The FL OIR-B1-1571 form is a critical document for affirming that personal injury protection services were provided. This guide will walk you through each step needed to complete this form online, ensuring that you understand every component.
Follow the steps to efficiently complete the FL OIR-B1-1571 form.
- Press the ‘Get Form’ button to access the FL OIR-B1-1571 form and open it in the appropriate online editor.
- Begin by entering the name of the insured person or their guardian in the designated field. Ensure that you print or type the name clearly to avoid any errors.
- Next, provide the signature of the insured person or their guardian in the marked area. This signature confirms their affirmation of the services received.
- Fill in the date on which the form is being completed. This helps to establish a clear timeline of events.
- If applicable, the licensed medical professional or medical director should print or type their name, providing their signature and the date in the designated section. This validates that they adhere to the statements outlined in the form, affirming that the services were explained sufficiently.
- Review all entries for accuracy and completeness. Ensure that all required fields are filled and any supplementary documents or bills are accurately completed.
- Once all fields are completed and reviewed, save your changes. Users can choose to download, print, or share the completed form for submission.
Take action now and fill out the FL OIR-B1-1571 form online to ensure timely processing of your claims.
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