Get Waiver Request Form
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How to fill out the Waiver Request Form online
Completing the Waiver Request Form online can be a manageable task with the right guidance. This form is designed for Durable Medical Equipment (DME) MAC Suppliers in Jurisdiction A to request an exception for electronic submission of claims as mandated by the Administration Simplification Compliance Act (ASCA).
Follow the steps to complete your Waiver Request Form online
- Click the ‘Get Form’ button to access the Waiver Request Form and open it in your online editor.
- In Section I, enter your provider or supplier name, provider number (PTAN), street address, city, state, and zip code. Provide the contact details for the authorized official, including their name, phone number, and email address. Ensure to include the authorized official's signature and the date.
- Move to Section II and select one reason for requesting the waiver from the options provided. If you are a small provider, indicate the number of full-time equivalent (FTE) employees. Be mindful to attach any necessary supporting documentation, such as payroll or tax records.
- If selecting 'No Method of Submitting Claims Electronically,' provide the required details for home oxygen therapy claims or other specified circumstances.
- In the unusual circumstances section, describe any service interruptions and provide relevant dates. If necessary, use an additional sheet for detailed explanations.
- Review all sections to confirm completeness and accuracy. When ready, save the changes you made to the form.
- Finally, download, print, or share the completed Waiver Request Form and ensure that it is mailed or faxed to NHIC, Corp at the provided addresses, along with all supporting documentation.
Complete your Waiver Request Form online today to ensure compliance and maintain smooth operations.
A request for waiver is a formal appeal asking to be excused from certain requirements or obligations. By submitting a Waiver Request Form, you provide the necessary details for your situation. This process allows individuals to request exceptions based on specific circumstances. Understanding this helps you navigate the waiver process more effectively.
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