Medicare Waiver Of Liability Statement Template

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Medicare Waiver of Liability Statement
Please complete the below form and return to AlphaCare of New York; Attn: Appeals &
Grievances Department at the below address. You may also fax this form to (347) 590 – 4319.
Member ID #: ___________________
Medicare/ HIC Number: _____________________
Member Name: ________________________________________________________________
Date(s) of Service: ______________________________________________________________
Provider Name: ________________________________________________________________
Health Plan: AlphaCare of New York_______________________________________________
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.
___________________________
___________________________
Signature
Print Name
___________________________
____________________________
Date
Telephone Number (with area code)
335   A dams   S treet,   S uite   2 600,   B rooklyn,   N .Y.   1 1201  

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