Get Waiver Of Liability For Deluxe Frames Patient039s Name Hic

Understanding how to complete the waiver of liability for deluxe frames is essential for ensuring that you acknowledge the additional costs associated with your eyewear choices. This guide will provide step-by-step instructions to help you accurately fill out the necessary information online.

Follow the steps to complete the form successfully.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. In the first section labeled 'PATIENT'S NAME,' input your full name as it appears on your insurance documents.
3. In the field marked 'HIC#,' enter your Health Insurance Claim number to ensure accurate processing.
4. Review the statement regarding the extra charge for deluxe frames and confirm your choice to purchase these by selecting the appropriate fields. Fill in the 'Retail Price' for the deluxe frames.
5. Next, fill in the 'Medicare allowable for standard frame' to acknowledge the reimbursement rate for standard frames.
6. Calculate and enter the 'Amount Owed by Patient for deluxe frame upgrade' based on the retail price minus the Medicare allowance.
7. Proceed to sign and date the form in the 'PATIENT SIGNATURE' and 'DATE' fields, confirming your understanding of the information provided.
8. For any deluxe lenses or features, repeat steps 2 through 7 in the designated section. Make sure to specify the retail price, Medicare allowance for standard lenses, and the amount owed for upgrades.
9. Once you have filled out both sections, review the entire document for accuracy, and make any necessary corrections.
10. Finally, save your changes, download the completed form, print it for your records, or share it as necessary.

Start filling out your documents online to ensure a smooth process.