Notice of Initiation of Treatment Form

Please see the attached Notice of Initiation of Treatment Letter. It should be used for every auto injury patient. It allows you to submit your first batch of bills within 75 days of treatment (instead of the normal 35 days).

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

There are several requirements:

  • Complete the form
  • Mail it to the auto insurance company within 21 days of the first date of service
  • Send it Certified mail
  • Keep a completed copy in your patient’s medical folder with the proof you mailed it within 21 days of the first date of service

While I still recommend mailing your initial group of bills to the insurance company weekly or bi-weekly, this form acts as a backup if your bills are ever late due to a mistake, change in staff, vacation, etc.. This only applies to the initial group of bills.

I left room at the top of the form so that you can put your letterhead there.


21 Day Notice
Notice of Initiation of Treatment

Insurance Company:

Address this form is being mailed to:

Certified Mail number:

Patient Name:

Insured Name:

Date of Loss:

Claim #:

Policy #:

______________________________

______________________________

______________________________

______________________________

______________________________

This document shall serve as formal notice to the insurer that the first examination or treatment of the claimant has occurred. While Florida Statute § 627.736 requires medical providers to submit bills to insurance companies within 35days of treatment, subsection (5)(c) allows medical providers to submit bills within 75 days of treatment if this notice is provided within 21 days of the first examination or treatment. Any deficiencies to this notice are deemed waived if they are not specifically objected to in writing before the 21 day window expires.

(c) With respect to any treatment or service, other than medical services billed by a hospital or other provider for emergency services and care as defined in s. 395.002 or inpatient services rendered at a hospital-owned facility, the statement of charges must be furnished to the insurer by the provider and may not include, and the insurer is not required to pay, charges for treatment or services rendered more than 35 days before the postmark date or electronic transmission date of the statement, except for past due amounts previously billed on a timely basis under this paragraph, and except that, if the provider submits to the insurer a notice of initiation of treatment within 21 days after its first examination or treatment of the claimant, the statement may include charges for treatment or services rendered up to, but not more than, 75 days before the postmark date of the statement.The injured party is not liable for, and the provider may not bill the injured party for, charges that are unpaid because of the provider’s failure to comply with this paragraph. Any agreement requiring the injured person or insured to pay for such charges is unenforceable.

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