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 injured person, who was involved in a motor vechicle accident, to be solicited to make a claim for Personal Injury Proctection benefits.
B. The treatment or services rendered were explained to the insured person, or his/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(14) and (15), Florida Statutes of 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)
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.