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Get WA Waiver Of Liability Statement - Community Health First

Provider Dates of Service Community Health Plan of Washington (HMO) 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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