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Get Waiver Form For: Non-Covered Services - Empire Blue Cross Blue ...

Wavier Form Statement Provider Signature The purpose of this waiver form is to inform Empire BlueCross BlueShield members before they receive a medical service that the service listed below is non-covered or not medically necessary or experimental/investigational. By signing this form I the physician acknowledge and agree that I have explained to the member that the service s listed are not a covered service s. Physician Signature Date IV. Reason.

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