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WAIVER OF LIABILITY STATEMENT Medicare/HIC Number Enrolled Name Provider Dates of Service Health Plan I hereby waive any right to collect payment from the above-mentioned enrolled for the aforementioned

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How to fill out waiver of liability statement

01

Read the waiver of liability statement carefully.

02

Fill out your personal information such as name, address, and contact details in the designated fields.

03

Identify the activities or events that the waiver applies to.

04

Include specific details about the risks associated with participating in the activities or events.

05

Declare that you understand and accept these risks.

06

Sign and date the waiver of liability statement.

07

Submit the completed waiver to the appropriate party.

Who needs waiver of liability statement?

01

Anyone who is engaging in activities or events that involve potential risks should consider having a waiver of liability statement.

02

Organizations or businesses that offer recreational activities, sports events, adventure outings, or any other activities where participants could potentially get injured or face financial loss may require participants to sign a waiver of liability statement.

03

Individuals or groups organizing events or activities where attendees or participants could face risks should have participants sign a waiver of liability statement to mitigate potential legal liabilities.

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