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Florida OIR-B1-1809: PIP Provider Eligibility Form

Florida PIP insurers ask a provider entity for this sworn statement to show it may receive medical benefits under section 627.736(1)(a), Florida Statutes. The signer attests that the entity is wholly owned by licensed physicians, chiropractic physicians or dentists and their close family, wholly owned by a hospital, or a licensed health care clinic that is accredited or meets the statute's medical director, licensure and specialty tests.

Who completes it

An executive officer, medical director or clinic director completes and signs the whole form under oath, based on personal knowledge, listing owners with license numbers and ownership percentages, the owning hospital, or the clinic's accreditation and licensure details. A notary completes the notarization block.

Submitting and payment

How to submit it
Provide the notarized form to the insurer covering the injured patient. After the first notarized submission to an insurer, copies may be sent to that insurer as long as the information has not changed.
Who pays
The patient's PIP insurer pays the medical benefits; this certification documents that the billing entity is one the statute allows to receive them.

Good to know

  • For practitioner-owned entities, list each licensed owner's name, Florida license number and percentage owned; ownership by practitioners and their spouse, parent, child or sibling must total 100%.
  • A licensed clinic not accredited by the Joint Commission, AOA, CARF or AAAHC must meet all three tests: a licensed medical director, more than 3 years of licensure or public trading, and four listed specialties.
  • The form was adopted under Rule 69O-170.0155, F.A.C., and the current printing is marked New 1/2013. Insurers commonly ask for it before paying a new clinic.
  • Its companion, OIR-B1-1773, certifies that individual services were lawfully provided, supervised, ordered or prescribed by a licensed practitioner.

Get the official form

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

Health Care Provider Certification of Eligibility for PIP Benefits

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

Which specialties count for the OIR-B1-1809 clinic test?

A licensed clinic that is not accredited must provide at least four of: general medicine, orthopedic medicine, radiography, physical therapy, physical medicine, physical rehabilitation, prescribing or dispensing outpatient prescription medication, and laboratory services. It must also have a medical director licensed under chapter 458, 459 or 460 and have been licensed more than 3 years or be publicly traded.

Does the OIR-B1-1809 need to be notarized for every claim?

No. It is notarized for the initial submission to each insurer. The form states that afterward it may be copied for later submissions to that same insurer, provided none of the information on it has changed. A change in ownership, accreditation or medical director calls for a new sworn, notarized form.