Healthcare Cost-Sharing Waiver Request Form
Use this form to request a waiver of healthcare cost-sharing charges and provide the details needed for review.
Requester Information
Full Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Patient/Member
*
Self
Parent/Guardian
Spouse/Partner
Other Authorized Representative
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Coverage and Waiver Request Details
Insurance Provider or Plan Name
*
Policy / Member Reference ID
Type of Cost-Sharing Requested for Waiver
*
Copay
Deductible
Coinsurance
Out-of-Pocket Maximum
Other
Requested Waiver Period or Date of Service
*
-
Month
-
Day
Year
Date
Requested Amount or Estimated Cost-Sharing Amount
*
Reason for Waiver and Supporting Details
Reason for requesting the waiver
*
Hardship or special circumstance details
*
Supporting documentation
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Waiver Acknowledgement
Signature
*
Submit Request
Submit Request
Should be Empty: