Medicare Waiver of Liability Form

 Supplier’s Notice:  Medicare will only pay for services that it determines to be “reasonable and necessary” under section 1862 (a) (1) of the Medicare law.  If Medicare determines that a particular service, although it would otherwise be covered, is not “reasonable and necessary” under Medicare program standards, Medicare will deny payment for that service.  I believe that in your case, Medicare is likely to deny payment for:

 _________________________________________________________(specify the particular service). 

Beneficiary’s Acknowledgement & Agreement to Pay:

My supplier has notified me that he or she believes, that in my case Medicare is likely to deny payment for the services identified above.  If Medicare denies the payment, I agree to personally and fully responsible for payment.

____________________________________________________________________
Patient’s Signature
_____/_____/_____
Date

Reasons That Can Be Used On the Waiver of Liability Form

The following statements can be used as reasons for your belief that Medicare is likely to deny payment:

___            Medicare does not usually pay for this many treatments or service

___            Medicare usually does not pay for this service

___            Medicare does not pay for this because it is a treatment that has yet to be proven effective

___            Medicare does not pay for this many services within this period of time

___            Medicare does not pay for such an extensive treatment

___            Medicare does not pay for this equipment for the illness or condition stated

___            Other_________________________________________________________

*General statements such as “I never know if Medicare will deny payment” are not acceptable.  The Medicare Part B beneficiary or his or her representative has the right to appeal a claim decision if there is dissatisfaction with the amount of payment, denial of coverage for services or supplies, or if the original claim was not acted upon within a reasonable time.  The supplier has the right to appeal a claim decision when he or she accepted assignment.  As a supplier providing items and services to Medicare beneficiaries, you may appeal an initial determination if (1) you accepted assignment on the claim or (2) you are acting as the duly authorized representative of the beneficiary.