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WAIVER OF LIABILITY STATEMENT - Lmc Health …

All cigna products and services are provided exclusively by or through operating subsidiaries of cigna Corporation. The cigna Name, logos, and other cigna marks are owned by cigna Intellectual Property, Inc. Leon Medical Centers Health Plans is an HMO plan with a Medicare contract. Enrollment in Leon Medical Centers Health Plans depends on contract renewal. Y0036_13_7094 CMS Accepted 02/17/2013 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 Signature_____ Date_____

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna Name, logos, and other Cigna marks are owned by Cigna Intellectual Property,

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Transcription of WAIVER OF LIABILITY STATEMENT - Lmc Health …

1 All cigna products and services are provided exclusively by or through operating subsidiaries of cigna Corporation. The cigna Name, logos, and other cigna marks are owned by cigna Intellectual Property, Inc. Leon Medical Centers Health Plans is an HMO plan with a Medicare contract. Enrollment in Leon Medical Centers Health Plans depends on contract renewal. Y0036_13_7094 CMS Accepted 02/17/2013 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 Signature_____ Date_____


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