Get 19 - Out Of Network Waiver Form - Hand Wrist Center

Filling out the 19 - Out Of Network Waiver Form - Hand Wrist Center online is a straightforward process that helps you acknowledge your understanding of the services and payments related to your treatment. This guide will provide you with clear, step-by-step instructions to ensure that you complete the form accurately.

Follow the steps to successfully complete the waiver form online.

1. Press the ‘Get Form’ button to access the 19 - Out Of Network Waiver Form and open it in your preferred online editor.
2. In the first blank field, enter your full name as the patient required to sign the waiver.
3. Input the name of your insurance plan in the designated space to specify that the providers are not in-network with your coverage.
4. Acknowledge that you understand the financial implications of receiving out-of-network services. This may include a lower payment rate from your insurance for these services.
5. Confirm that you agree to pay 50% of the anticipated total charges immediately and for each day of service to follow.
6. Fill in your responsibilities regarding financial correspondence from The Hand and Wrist Center and the billing service. Be prepared to pay any outstanding amounts if the initial payment is insufficient.
7. If you are completing the form on behalf of someone else, make sure to provide your full name and state your relationship in the provided space.
8. Sign the form by entering your signature below the patient signature line.
9. Enter today’s date in the specified field for record-keeping purposes.
10. Once you have filled out all required fields, ensure to save your changes. You may also choose to download, print, or share the completed form as needed.

Complete your waiver form online today to ensure a smooth process at The Hand and Wrist Center.