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Waiver of Liability (WOL) Statement Member Name: Medicare/HIC Number Molina Dual Options Medicare Medicaid Plan Member ID Number: Provider Name: Date of Service: I hereby waive any right to collect

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How to fill out waiver or liability statement

01

Start by reading the waiver or liability statement carefully to understand its contents.

02

Fill in your personal information accurately, including your full name, address, and contact information.

03

Provide any necessary details about the activity or event for which the waiver is being filled out.

04

Review any terms and conditions mentioned in the statement and make sure you agree to them.

05

Sign and date the waiver or liability statement.

06

If required, have a witness sign the document as well.

07

Keep a copy of the filled-out waiver for your records.

Who needs waiver or liability statement?

01

Anyone participating in an activity or event that involves potential risks or hazards may need to fill out a waiver or liability statement.

02

This includes but is not limited to participants in adventure sports, recreational activities, fitness classes, organized tours, and events where there is a possibility of injury or harm.

03

Venue owners, organizers, and businesses may also require individuals to sign waivers to protect themselves against legal claims.

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What is waiver or liability statement?

A waiver or liability statement is a legal document where an individual acknowledges and assumes certain risks associated with participating in an activity or event.

Who is required to file waiver or liability statement?

Individuals participating in an activity or event where there may be risks involved are usually required to file a waiver or liability statement.

How to fill out waiver or liability statement?

To fill out a waiver or liability statement, one must carefully read the document and provide accurate information about themselves and acknowledge the risks involved.

What is the purpose of waiver or liability statement?

The purpose of a waiver or liability statement is to protect the organizers or hosts of an activity or event from legal liability in case of accidents or injuries.

What information must be reported on waiver or liability statement?

The waiver or liability statement typically requires personal information of the participant, acknowledgment of risks involved, and a signature.

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