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Florida OIR-B1-1773: PIP Lawful Services Certification

Florida PIP insurers rely on this sworn statement to confirm that medical services or care billed under section 627.736(1)(a), Florida Statutes, were lawfully provided, supervised, ordered or prescribed by a physician licensed under chapter 458 or 459, a dentist under chapter 466 or a chiropractic physician under chapter 460. It may be submitted with the claim form and is notarized for the first submission to each insurer.

Who completes it

An executive officer, medical director or clinic director of the provider entity signs it under oath, listing the name, address and Florida practice license number, with any prefix or suffix, of each person who provided, supervised, ordered or prescribed the care. A notary completes the notarization block.

Submitting and payment

How to submit it
Send the notarized form to each PIP insurer, which may be done with the claim form. After that first notarized submission, a copy may go to the same insurer as long as nothing on the form has changed.
Who pays
The patient's PIP insurer pays the underlying medical claim; this certification documents that the billed care meets the lawful-provision requirement of section 627.736(1)(a).

Good to know

  • Check every manner that applies: provided, supervised, or ordered or prescribed. When the care was ordered or prescribed, attach a copy of the order or prescription.
  • The signer swears under penalty of perjury and adds their Board or Department of Health license number with suffix and the entity's corporate name as filed with the Florida Department of State.
  • It is used mainly for therapy, massage and other services billed under a physician's supervision or prescription rather than performed by the physician directly.
  • The current version is OIR-B1-1773, published 5/2008. Its companion, OIR-B1-1809, certifies that the provider entity itself is eligible to receive PIP benefits.

Get the official form

Download the current version from the source each time; forms change without notice.

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

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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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

Does Florida form OIR-B1-1773 have to be notarized every time?

No. The form is sworn and notarized for the initial submission to an insurer. After that, the provider may send a copy to that same insurer, provided there has been no change to the information on the form. A different insurer, or a change in the listed practitioners or entity details, calls for a newly notarized form.

Who can sign the OIR-B1-1773 certification?

The signature line is for an executive officer, medical director or clinic director of the entity or clinic. That person swears under penalty of perjury that the care was lawfully provided, supervised, ordered or prescribed by a Florida-licensed MD, DO, dentist or chiropractic physician, and gives their own license number.

What is the difference between OIR-B1-1773 and OIR-B1-1809?

OIR-B1-1773 certifies how specific services were delivered: provided, supervised, ordered or prescribed by a licensed practitioner. OIR-B1-1809 certifies that the provider entity qualifies to receive PIP benefits at all, as a practitioner-owned or hospital-owned entity or an accredited or qualifying licensed health care clinic. Both are sworn and notarized.