Form- Affidavit of Inoperability

Dear Provider;

Please see the attached Affidavit of Inoperability. It is to be used when a patient is treating at your office, owns a motor vehicle, and goes through another person’s PIP insurance policy.

Click here to see a nice PDF form that you can download for free

This form should be used to “CYA” in the event the insurance company claims the patient owned a motor vehicle and should have used (or had) their own PIP insurance. It should not be sent to the insurance company unless they deny your PIP bills.

Because patient’s can be hard to reach after they stop treating it is best to get the patient to complete this affidavit while they are still treating. Also, please make sure they get this form notarized.

Sincerely,

Abraham S. Ovadia, Esq.

abe@wesetthestandards.com

STATE OF FLORIDA

COUNTY OF ___________________

AFFIDAVIT OF INOPERABILITY

After being duly sworn, I state upon personal knowledge that:

  1. I am ___________________________; I am over the age of 18; and I am legally competent.
  1. I was a driver / passenger / pedestrian (CIRCLE ONE) involved in a motor vehicle collision on ___________________________.
  1. I own a motor vehicle described as:

Year: _______________________

Make: _______________________

Model: _______________________

  1. The above motor vehicle is inoperable because (BE AS SPECIFIC AS POSSIBLE):

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

_________________________________________________________________.

5. The above motor vehicle has been inoperable since _________________.

  1. I do not own any other motor vehicle for which security is required under Florida Statutes Chapter 627 nor do I live with a relative who owns such a vehicle.

Further Affiant Sayeth Naught.

________________________

Patient Signature

­________________________

Print Patient Name

Sworn to before me, a Notary Public of this State, by __________________________, who is/not personally known to me and presented ___________________________ as identification this _____ Day of _____________________, 20___.

________________________

Notary Public

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