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Appendix 6 - Waiver of Liability Statement Rev. 22 05-09-03 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 .

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