Non Participating Provider Appeal Waiver Of Liability Form

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WAIVER OF LIABILITY STATEMENT
ConnectiCare Grievance and Appeal Department – 2nd Floor
SR# ____________
________________________
__________________________
Enrollee’s Name
Medicare/HIC Number
__________________________
_________________________
Provider
Dates of Service
ConnectiCare______________
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.
_______________
___________________
Signature
Date

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