Standard Disclosure Form – Fill Out and Use This PDF

Updated: Nov 2, 2026

The Standard Disclosure form is a crucial document within the realm of personal injury protection, especially after an individual has been involved in a motor vehicle accident. This form ensures that all services and treatments claimed have been rendered, and it establishes a transparent communication between the insured person (or guardian), the medical provider, and the insurer. By affirming statements regarding the legitimacy of services provided, the rights of the insured, and the responsibilities of the medical provider, it plays a pivotal role in the claims process.

Filling out and submitting this form accurately is essential for the smooth processing of any claims related to personal injury protection. Ensure your claim is managed effectively by clicking the button below to start the Standard Disclosure form.

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Standard Disclosure Form PDF Details

In the realm of insurance regulation, particularly concerning personal injury protection and the initial treatment or service provided after a motor vehicle accident, the Standard Disclosure and Acknowledgement Form plays a critical role. This document, which is an important component in the process of claiming benefits, serves to affirm several key points. First, it verifies that the claimed services or treatments were indeed rendered to the insured person. Additionally, it emphasizes the responsibility of the insured person (or their guardian) to ensure these services have been provided and not solicited improperly. The form also outlines the process and potential entitlements related to the correction of billing errors, including the possibility of the insured person receiving a portion of the reduction in billed amounts. Furthermore, licensed medical professionals or directors affirm their non-involvement in solicitation and the propriety of the billing process through this form. Its significance is underscored by the inclusion of a provision that highlights the legality of the information provided and the consequences of fraudulent claims. Completion and submission of this form, required under specific Florida Statutes, are critical steps in the insurance claim process, reinforcing the emphasis on transparency, accountability, and proper procedural conduct.

Question	Answer
Form Name	Standard Disclosure Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	state of florida disclosure form, florida standard disclosure form, b1 1571, oir b1 1571 form

How to Fill Out Form OIR-B1-1571

Form OIR-B1-1571 at a glance

What it is: The Standard Disclosure and Acknowledgement Form Personal Injury Protection, Initial Treatment or Service Provided, OIR-B1-1571 Pub. 1/2004, is affirmed by the undersigned insured person (or guardian of such person).

Who signs: The Insured Person (patient receiving treatment or services) or Guardian of Insured Person signs and enters Name (PRINT or TYPE), Signature and Date. The Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable, signs by his/ her own hand and enters Name (PRINT or TYPE), Signature and Date.

A filled-in Form OIR-B1-1571 example: an insured person and a physician sign

Form OIR-B1-1571 example filled out, example: an insured person and a physician sign — Dana Sample signs the disclosure form after a clinic visit. Dana was treated at a clinic on March 3, 2026, and the clinic's physician signs too. The picture shows the signed page, and none of its entries is real.

How to fill out Form OIR-B1-1571, box by box

The services or treatment set forth

The services or treatment set forth on this form were actually rendered. This means that those services have already been provided.

Insured Person (patient receiving treatment or services) or Guardian of Insured Person

The Insured Person (patient receiving treatment or services) or Guardian of Insured Person enters Name (PRINT or TYPE), Signature and Date.

You have the right and the duty to confirm that the services have already been provided.

You were not solicited by any person to seek any services from the medical provider of the services described.

The medical provider has explained the services to you for which payment is being claimed.

If you notify the insurer in writing of a billing error, you may be entitled to a portion of any reduction in the amounts paid by the motor vehicle insurer. If entitled, your share would be at least 20% of the amount of the reduction, up to $500 (checked November 1, 2026).

Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 and also the statements A to D.

A. You have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal Injury Protection benefits.

B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.

C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner.

D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627.732 (15) and (16), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.

Statement of Claim, felony and the original

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree per Section 817.234(1)(b), Florida Statutes. Note: The original of this form must be furnished to the insurer pursuant to Section 627.736(4)(b), Florida Statutes and may not be electronically furnished. Failure to furnish this form may result in non-payment of the claim.

Sources

[1] Form OIR-B1-1571 (Pub. 1/2004), Office of Insurance Regulation, Florida (the Official source link on this page).