WAIVER FORM


NOTE: The waiver cannot be utilized for services considered to be content of another service provided.

A. SITUATIONS REQUIRING A WAIVER

1. Medical necessity denials
2. Utilization denials
3. Deluxe features (Applicable to deluxe orthopedic or prosthetic appliances as specified in the member contract)
4. Patient demanded services
5. Experimental/investigational procedures

B. THE WAIVER FORM MUST BE

1. Signed before receipt of service.
2. Patient, service, and reason specific.
3. Date of service and dollar amount specific.
4. Retained in the patient's file at the provider's place of business. (The waiver form is no longer required with claims submission. Use the GA modifier for all electronic and paper claims.)
5. Presented on an individual basis to the patients. It may not be a blanket statement signed by all patients.
6. Acknowledged by patient that he or she will be personally responsible for the amount of the charge, to include an approximate amount of the charge at issue.

NOTE: If the waiver is not signed before the service being rendered, the service is considered a contracting provider write-off, unless there are extenuating circumstances

LIMITED PATIENT WAIVER Form

Patient’s Name:
Provider Name:
Identification Number:
Provider Address:
Provider Number:
The provider must document in the patient record the discussion with the patient regarding the following service(s).