Standard Disclosure Form PDF Details

The Standard Disclosure Form is a document that provides disclosure of all potential risks and conflicts of interest related to a particular investment opportunity. The form must be completed by the person or entity offering the investment opportunity, and it is typically used in conjunction with private placements or investments in startup companies. By completing and submitting the Standard Disclosure Form, you are providing potential investors with all the information they need to make an informed decision about whether or not to invest in your company.

Here is the details regarding the form you were seeking to complete. It can show you the time it should take to finish standard disclosure form, exactly what fields you will need to fill in and a few other specific details.

QuestionAnswer
Form NameStandard Disclosure Form
Form Length1 pages
Fillable?Yes
Fillable fields8
Avg. time to fill out1 min 51 sec
Other namesflorida disclosure form, standard disclosure, state of florida disclosure form, oir b1 1571

Form Preview Example

OFFICE OF INSURANCE REGULATION

Bureau of Property & Casualty Forms and Rates

Standard Disclosure and Acknowledgement Form

Personal Injury Protection - Initial Treatment or Service Provided

The undersigned insured person (or guardian of such person) affirms:

1.The services or treatment set forth below were actually rendered. This means that those services have already been provided.

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

3.I was not solicited by any person to seek any services from the medical provider of the services described above.

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

5.If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

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

Name (PRINT or TYPE)

Signature

Date

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:

A.I 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.

Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable (Signature by his/ her own hand):

Name (PRINT or TYPE)

Signature

Date

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.

OIR-B1-1571

Pub. 1/2004

How to Edit Standard Disclosure Form Online for Free

The florida disclosure form completing course of action is effortless. Our software allows you to work with any PDF file.

Step 1: You should select the orange "Get Form Now" button at the top of this webpage.

Step 2: Now you can edit your florida disclosure form. This multifunctional toolbar allows you to add, eliminate, improve, and highlight content material or undertake similar commands.

Enter the details requested by the software to fill out the document.

portion of empty spaces in fl disclosure form

Write down the appropriate details in Name, PRINT, or, TYPE Signature, Date, and O, IRB, Pub part.

Finishing fl disclosure form step 2

Step 3: Select the Done button to confirm that your completed form may be exported to each electronic device you decide on or delivered to an email you specify.

Step 4: Prepare a minimum of two or three copies of the document to prevent any sort of potential future concerns.

Watch Standard Disclosure Form Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .