Get Noncovered Services Waiver Form - Great Plains Laboratory

The NonCovered Services Waiver Form from Great Plains Laboratory is essential for individuals seeking services potentially not covered by TRICARE. This guide provides clear, step-by-step instructions to complete the form online effectively.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to access the NonCovered Services Waiver Form and open it in the document editor.
2. Complete the date field by entering the current date to indicate when the form is being filled out.
3. Fill in the sponsor name and sponsor ID to identify the individual responsible for the patient under TRICARE.
4. Provide the patient name and patient ID to ensure the correct individual is associated with the waiver.
5. In the Service Description section, note that every test offered by Great Plains Laboratory may be denied by TRICARE South. It's crucial to understand that the full list price for every test could be the patient's responsibility.
6. Document the diagnosis in the relevant field, recognizing that any diagnosis may potentially be classified as non-specific or non-covered.
7. Specify the date of service to indicate when the medical services were received or will be received.
8. Fill in the provider name as The Great Plains Laboratory, Inc., including their Tax Identification Number (TIN) and address for verification.
9. Ensure the physician's signature is obtained, affirming that the individual understands these services may not be covered under TRICARE and agrees to accept financial responsibility.
10. Collect the patient's signature along with the date to confirm their acknowledgment and agreement to the waiver terms.
11. If applicable, have the beneficiary's or legal guardian's signature and date added for official validation.
12. Lastly, secure a witness signature and date to complete the form's signing process.
13. Once all sections are filled out and signed, you can save your changes, download the document for your records, print it, or share it as needed.

Complete the NonCovered Services Waiver Form online today to ensure your medical services are processed correctly.