Fillable Waiver of Liability Statement (Blue Cross and Blue Shield of Texas)

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Waiver of Liability Statement (Blue Cross and Blue Shield of Texas)

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The Waiver of Liability Statement (Blue Cross and Blue Shield of Texas) form is 1 page long and contains:

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  • 6 other fields

Country of origin: US
File type: PDF

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Waiver of Liability Statement
Enrollee’s Name Enrollee ID Number
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 (Blue Cross and Blue Shield of Texas)

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Completed 10 February 2021

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