Surgery Center: Medicare Waiver of Liability

Form Template

Medicare will only pay for services that it determines to be “reasonable and necessary” under Section 1862(A) (1) of the Medicare Law.

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If Medicare determines that a particular service, although it would otherwise be covered, is “not reasonable and necessary” under Medicare program standards, Medicare will deny payment for that service. If physicians feel that the service listed in the app is in a patient's medical interest or that Medicare is likely to deny payment for this service for the reason stated in the app. Patients can sign and acknowledge that they have been notified by my physician that believes that, in their case, Medicare is likely to deny payment for the service identified in the app for the reason(s) stated. If Medicare denied payment, patient can sign and agree to be personally and fully responsible for payment. Surgical centers can use the Surgery Center: Medicare Waiver of Liability mobile app with a smartphone to have patients complete a Medicare Waiver of Liability. All GoCanvas apps can be made HIPAA compliant.

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