Get Humana Waiver Of Liability

Completing the Humana Waiver Of Liability online is a straightforward process that ensures proper documentation of services denied by a health plan. This guide will provide you with clear instructions to help you navigate each section of the form effectively.

Follow the steps to complete your waiver accurately.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. In the first field, enter the member’s name as it appears on their health records. Ensure the spelling is accurate to avoid any issues with processing.
3. Provide the Medicare Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI). This is a crucial identification number that facilitates the correct identification of the member's account.
4. Enter the provider’s name who rendered the services. This should be the individual or organization responsible for the treatment or service provided.
5. Indicate the date(s) of service in the designated field. It is important to list the exact dates when the services were delivered.
6. Input the Humana health plan details, ensuring you select the correct plan that correlates with the member.
7. Insert the Humana ID number associated with the member. This number is vital for the claims process and should be filled accurately.
8. Read the waiver statement carefully. By signing, you acknowledge that you will not collect payment from the enrollee for the services denied.
9. Sign the form at the designated space for the provider signature. This shows acknowledgment and agreement to the terms outlined in the waiver.
10. Enter your tax identification number in the space provided. This is necessary for tax and billing purposes.
11. Provide your telephone number for any follow-up or clarification required by the health plan.
12. Finally, fill in the date of signing to complete the form. Ensure all fields are thoroughly checked before submission.
13. Once you have completed the form, you can save changes, download, print, or share the document as needed.

Complete your Humana Waiver Of Liability online today to ensure timely submission and processing.