Fillable WAIVER OF LIABILITY STATEMENT Medicare/HIC Number (Absolute Total Care)

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WAIVER OF LIABILITY STATEMENT Medicare/HIC Number (Absolute Total Care)

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The WAIVER OF LIABILITY STATEMENT Medicare/HIC Number (Absolute Total Care) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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WAIVER OF LIABILITY STATEMENT
Medicare/HIC Number
Enrollee’s Name
Provider Dates of Service
Health Plan
I hereby waive any right to collect payment from the above-mentioned enrollee for the
aforementioned services for which payment has been denied by the above-referenced health plan.
I understand that the signing of this waiver does not negate my right to request further appeal under
42 CFR 422.600.
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WAIVER OF LIABILITY STATEMENT MedicareHIC Number (Absolute Total Care)

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Completed 5 May 2021

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