Sample Waiver of Non-Covered Services Form

A sample Waiver of Non-Covered Services Form was developed to illustrate the information required by TRICARE to bill a beneficiary for a non-TRICARE covered service. The form allows a network (contracted) provider to charge a TRICARE beneficiary for services that are not a covered TRICARE benefit when the beneficiary has agreed, in writing, to waive his or her balance-billing protection. Remember that Active Duty Service Members cannot waive or be billed for non-covered services.