Alert: The patient has been relieved of liability of payment of these
the date you receive this notice. You must make the request through this
office.
items and services under the limitation of liability provision of the
law. The provider is ultimately liable for the patient's waived charges,
including any charges for coinsurance, since the items or services were
not reasonable and necessary or constituted custodial care, and you knew
or could reasonably have been expected to know, that they were not
covered. You may appeal this determination. You may ask for an appeal
regarding both the coverage determination and the issue of whether you
exercised due care. The appeal request must be filed within 120 days of
