Florida's personal injury protection (PIP) law requires this standard disclosure at the initial treatment after a motor vehicle accident. The insured patient affirms the billed services were rendered and explained, and the licensed professional who rendered them, or the medical director, certifies no solicitation, informed consent, a complete bill and proper coding. The original goes to the PIP insurer with the bill, and a claim sent without it may not be paid.
The insured person, or the guardian of the insured person, signs the patient affirmations (statements 1 to 5). The licensed medical professional who rendered the treatment, or the medical director if applicable, affirms statements A to D and signs by his or her own hand, with printed name and date.
The insured person, or the guardian of the insured person, affirms that the services or treatment listed were actually rendered, meaning already provided rather than planned. Enter those services in the fields under statement 1 so they match the accompanying bill. The insured also affirms the right and duty to confirm services were provided, that nobody solicited them to seek care from this provider, and that the provider explained the services being billed. Statement 5 tells the insured that reporting a billing error to the insurer in writing may entitle them to a share of any reduction in the amount paid.
The patient who received the treatment or services, or the guardian, prints or types a name, signs and dates. This block sits above the professional's block on the same page, so one form carries both signatures to the insurer. The patient's own signature confirms the services were rendered and explained, and a 'signature on file' notation is not accepted in its place.
The professional affirms statement 1 and four more: (A) no solicitation of the insured, or causing the insured to be solicited, to claim PIP benefits; (B) the services were explained well enough for the insured to sign with informed consent; (C) the accompanying bill is properly completed in all material provisions, with every request for information answered truthfully, accurately and substantially completely; (D) the procedure coding is proper, with no upcoding, unbundling, or invalid or not medically necessary diagnostic test as defined in the cited Florida Statutes.
Print or type the professional's name, sign by hand and date. The caption requires a signature by the professional's own hand, so a stamped signature or a 'signature on file' entry does not meet it. Sign only after reviewing the bill that accompanies the form, because statements C and D vouch for its completeness and coding.
The form closes with the warning that knowingly filing a claim containing false, incomplete or misleading information with intent to injure, defraud or deceive an insurer is a third-degree felony under section 817.234(1)(b), Florida Statutes. The note below it states that the original must be furnished to the insurer under section 627.736(4)(b), may not be furnished electronically, and that failure to furnish it may result in non-payment of the claim.
Download the current version from the source each time; forms change without notice.
Standard Disclosure and Acknowledgement Form - Personal Injury Protection - Initial Treatment or Service Provided
This form is a Word template, not a PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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.
Sources for this guide
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No. The note at the bottom of the form says the original must be furnished to the insurer under section 627.736(4)(b), Florida Statutes, and may not be furnished electronically. The professional's block is captioned 'Signature by his/her own hand,' and a 'signature on file' notation is not accepted. Print the Word form, complete it, and have both parties sign in ink.
The licensed medical professional who rendered the treatment or services signs it, or the medical director if applicable. By signing, that person affirms the services were actually rendered, that the insured was not solicited, that the services were explained well enough for informed consent, and that the accompanying bill and its procedure coding are proper.
No. Emergency department and ambulance services are exempt from the standard disclosure and acknowledgement requirement. The form applies to the initial treatment or service billed to PIP by other providers, where the insured patient and the treating professional both sign at the first visit after the accident.
The form itself states that failure to furnish it may result in non-payment of the claim. Because the insurer needs the original, keep the signed paper form with the initial bill and send it together with the CMS-1500 or UB-04 rather than as a scanned or electronic attachment.