Oir b1 1809 fillable-2026

The document is a certification form for health care providers in Florida to attest their eligibility for Personal Injury Protection (PIP) benefits under Florida Statutes. It requires detailed information about the ownership of the health care entity, including names, addresses, license numbers, and ownership percentages of licensed practitioners and family members. The form also outlines specific criteria for clinics to qualify for PIP benefits, such as accreditation and medical director requirements.

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Click ‘Get Form’ to open the oir b1 1809 fillable in the editor.
Begin by entering your name and title in the designated fields at the top of the form. Ensure that you print or type clearly for legibility.
In the section regarding ownership, check all applicable boxes that describe the entity providing medical benefits. Fill in the required details such as names, addresses, and Florida practice license numbers for each licensed health care practitioner.
If there are family member owners, provide their information in the specified fields, including their relationship to you and percentage owned. Make sure that all percentages add up to 100%.
Complete any additional sections related to hospital ownership or clinic accreditation as necessary, ensuring all required information is filled out accurately.
Finally, sign and date the form at the bottom. If notarization is required, ensure it is completed before submission.

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