Auto insurance no-fault and PIP forms for clinicians

The claim, treatment plan, assignment, notice and appeal forms providers sign when an auto insurer pays for accident care in New York, New Jersey, Florida and Michigan.

When an auto insurer pays for accident care under no-fault or personal injury protection (PIP), New York, New Jersey and Florida prescribe the forms providers sign. In New York, the treating provider verifies diagnosis, causation and disability on the NF-3 and takes an assignment on the NF-AOB, while hospitals use the NF-4 and NF-5. New Jersey requires the Attending Provider Treatment Plan (APTP) for decision point review and precertification. Florida requires the Standard Disclosure and Acknowledgement Form (OIR-B1-1571) at the first PIP treatment.

Deadlines decide payment. New York claims must reach the insurer within 45 or 180 days of treatment, depending on the policy endorsement. New Jersey providers notify the PIP insurer within 21 days of starting treatment, and the insurer must decide an APTP within 3 business days. Florida's OIR-B1-1571 needs the provider's own signature on the original, and the OIR-B1-1809 and OIR-B1-1773 certifications are notarized. Michigan providers appeal utilization review decisions on FIS 2356. Vero Documents fills these PDFs from the visit note and the chart.

Florida

OIR-B1-1571

Standard Disclosure and Acknowledgement Form - Personal Injury Protection - Initial Treatment or Service Provided

Mandatory PIP form signed at the initial treatment in which the insured affirms services were rendered and explained and the treating professional certifies the bill and coding are proper, as required by s. 627.736(5)(e), F.S.

Completed by: Licensed medical professional rendering treatment (or medical director) and the insured patient or guardian
Issued by: Florida Office of Insurance Regulation (adopted by the Financial Services Commission, Rule 69O-176.013, F.A.C.)
Format: Word document
Language: English

Official page Word file How to fill it in

OIR-B1-1809

Health Care Provider Certification of Eligibility for PIP Benefits

Sworn, notarized certification that a provider entity qualifies to receive PIP medical benefits under s. 627.736(1)(a), F.S. (practitioner-owned, hospital-owned, or an accredited or qualifying licensed health care clinic).

Completed by: Executive officer, medical director or clinic director of the provider entity
Issued by: Florida Office of Insurance Regulation (Rule 69O-170.0155, F.A.C.)
Format: PDF
Language: English

Official page PDF Form details

OIR-B1-1773

Certification of Medical Services or Care Lawfully Provided, Supervised, Ordered or Prescribed Pursuant to Section 627.736(1)(a), Florida Statutes

Sworn, notarized certification that PIP medical services or care were lawfully provided, supervised, ordered or prescribed by a Florida-licensed MD/DO, dentist or chiropractic physician.

Completed by: Executive officer, medical director or clinic director of the provider entity (licensed practitioner)
Issued by: Florida Office of Insurance Regulation
Format: PDF
Language: English

Official page PDF Form details

Michigan

FIS 2356

Provider Appeal Request (Auto Insurance Utilization Review)

Form a health care provider files to appeal an auto insurer's or the MCCA's utilization review determination (medical necessity and/or cost) under MCL 500.3157a and Mich Admin Code R 500.65.

Completed by: Health care provider (physician, hospital, clinic or other treating provider)
Issued by: Michigan Department of Insurance and Financial Services, Utilization Review Section
Format: Fillable PDF
Language: English

Official page PDF Form details

New Jersey

APTP Form Version 2.1

Attending Provider Treatment Plan

Uniform PIP form a treating provider submits to the auto insurer for decision point review or precertification of proposed treatment, diagnostic tests and durable medical equipment.

Completed by: Treating physician, chiropractor, physical therapist or other attending provider
Issued by: New Jersey Department of Banking and Insurance (uniform form under N.J.A.C. 11:3-4, Order A16-101)
Format: PDF
Language: English

Official page PDF Form details

Personal Injury Protection Benefits Conditional Assignment of Benefits

Insurer-specific assignment by which the patient directs PIP payment to the provider and the provider agrees to the insurer's decision point review/precertification plan, internal appeals and PIP dispute resolution under N.J.A.C. 11:3-5.

Completed by: Patient and treating provider (both sign)
Issued by: New Jersey PIP insurers (each insurer's DOBI-approved Decision Point Review Plan; GEICO version shown)
Format: Sent for each case
Language: English

Official page PDF Form details

N.J.A.C. 11:3-25 Appendix A

Notification of Commencement of Medical Treatment

Notice a treating health care provider files with the PIP insurer within 21 days of starting treatment of an auto accident patient.

Completed by: Treating health care provider
Issued by: New Jersey Department of Banking and Insurance
Format: PDF
Language: English

Official page PDF Form details

Version 1.2

New Jersey PIP Pre-Service Appeal Form

Uniform form a provider uses to appeal an auto insurer's denial or modification of a decision point review / precertification request before treatment is rendered (internal appeal required before arbitration).

Completed by: Treating provider (holding an assignment of benefits)
Issued by: New Jersey Department of Banking and Insurance (uniform internal appeal form, Order A17-103)
Format: PDF
Language: English

Official page PDF Form details

Version 1.2

New Jersey PIP Post-Service Appeal Form

Uniform form a provider uses to appeal an auto insurer's payment decision on PIP services already rendered (bill and line-level appeal codes).

Completed by: Treating provider or billing office (holding an assignment of benefits)
Issued by: New Jersey Department of Banking and Insurance (uniform internal appeal form, Order A17-103)
Format: PDF
Language: English

Official page PDF Form details

New York

NF-3

Verification of Treatment by Attending Physician or Other Provider of Health Service

Prescribed no-fault claim form on which a treating physician or other non-hospital provider verifies diagnosis, causation, disability (unable-to-work dates), future treatment and services rendered so the auto insurer can pay basic economic loss benefits.

Completed by: Attending physician or other provider of health service (chiropractor, PT, acupuncturist, psychologist, etc.); patient signs items 20/21 if authorizing direct payment or assigning benefits
Issued by: New York State Department of Financial Services (prescribed under Insurance Regulation 68, 11 NYCRR 65)
Format: Fillable PDF
Language: English

Official page PDF How to fill it in

NF-AOB

Assignment of Benefits Form (for accidents occurring on and after 3/1/02)

Prescribed assignment by which the patient assigns no-fault benefits to a hospital or health care provider, and the provider certifies it has received no payment from the patient and will not pursue the patient directly.

Completed by: Patient (assignor) and health care provider (assignee), both sign
Issued by: New York State Department of Financial Services (prescribed under Insurance Regulation 68, 11 NYCRR 65)
Format: Fillable PDF
Language: English

Official page PDF How to fill it in

More US forms

Workers' compensationState programs, plus federal OWCP245 forms Driver medicalsState DMVs154 forms Insurance companiesNational carriers128 forms

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

When does the NF-3 have to reach the insurer?

As soon as reasonably possible, and no later than 45 or 180 days after treatment, depending on the policy endorsement. The attending physician or other provider completes items 1 to 19, covering diagnosis, causation, disability and services, and signs on page 3. The patient signs items 20 and 21 to authorize direct payment or assign benefits. Services are billed under the Workers' Compensation fee schedules adopted by Insurance Regulation 83.

What is New Jersey's 21-day notice?

The Notification of Commencement of Medical Treatment, set out in N.J.A.C. 11:3-25 Appendix A. The treating provider files this one-page form with the patient's PIP insurer within 21 days of starting treatment, listing the provider, patient, insured, insurer, policy number, accident date and first treatment date. Late notice can reduce payment for the treatment.

Can I use 'signature on file' on the Florida OIR-B1-1571?

No. The licensed professional who renders treatment, or the medical director, signs the provider attestation by hand, and the insured signs too. The original goes to the PIP insurer with the bill and can't be furnished electronically. Emergency department and ambulance services are exempt. Failing to furnish the form may mean the bill isn't paid. The state publishes it only as a Word document.

How do I appeal a Michigan auto insurer's utilization review decision?

File a Provider Appeal Request (FIS 2356) with the Department of Insurance and Financial Services within 90 days of the insurer's determination. Email it with a narrative, the determinations, the billing form and the records; mail is also accepted, but fax is not. The appeal can cover medical necessity, cost or both. Michigan has no state-prescribed clinician PIP claim form.