where can I find a sample of a wellness waiver?

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Where can I find a sample of a General Wellness Waiver? we have a lot of patients that come in for their wellness exam and we do labs on them but not all labs are being covered and they are denied as not medically necessary and we don't have a waiver on file. All I am looking for is some help with writing one or finding one that I can mimic and make our own. is this what we should be doing so that we can bill the patient for the non covered services?
 
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