Medicare
Medicare Private Contract
This agreement is entered into this ____ day of _________________________________, by and between
____________________ (hereinafter called “physician”), whose principal medical office is located at
Michael A. Ciampi, M.D.
___________________________________ and ___________________________________ (a patient enrolled in
380 Lincoln Street, South Portland, ME 04106
Medicare Part B, hereinafter called “patient”), who resides at ______________________________________________.
Background
A provision in the Social Security Act permits Medicare beneficiaries and physicians to contract privately outside
of the Medicare program. Under the law as it existed prior to January 1, 1998, a physician was not permitted to
charge a patient more than a certain percentage in excess of the Medicare fee schedule amount. A new provision,
which became effective on January 1, 1998, permits physicians and patients to enter into private arrangements
through a written contract under which the patient may agree to pay the physician more than that which would
be paid under the Medicare program.
A “private contract” is a contract between a Medicare beneficiary and a physician or other practitioner who has
opted out of Medicare for two years for all covered items and services he/she furnishes to Medicare beneficiaries.
In a private contract, the Medicare beneficiary agrees to give up Medicare payment for services furnished by the
physician/practitioner and to pay the physician/practitioner without regard to any limits that would otherwise
apply to what the physician/practitioner could charge.
The purpose of this contract is to permit the patient (who is otherwise a Medicare beneficiary) and the physician
to take advantage of this new provision in the Medicare law and sets forth the rights and obligations of each. This
agreement is limited to the financial arrangement between Physician and Patient and is not intended to obligate
either party to a specific course or duration of treatment.
Patients and physicians who take advantage of this provision are not permitted to submit claims or to expect
payment for those services from Medicare.
Exception:
In an emergency or urgent care situation, a physician/practitioner who opts out may treat a Medicare beneficiary
with whom he/she does not have a private contract and bill for such treatment. In such a situation, the
physician/practitioner may not charge the beneficiary more than what a nonparticipating physician/practitioner
would be permitted to charge and must submit a claim to Medicare on the beneficiary’s behalf. Payment will be
made for Medicare covered items or services furnished in emergency or urgent situations when the beneficiary
has not signed a private contract with that physician/practitioner.
A. Obligations of Physician
1. Physician agrees to provide such treatment as may be mutually agreed upon by the parties and at mutually
agreed upon fees.
2. Physician agrees not to submit any claims under the Medicare program for any items or services even if such
items or services are otherwise covered by Medicare.
National Government Services, Inc.
Page: 1 of 2
Form
#: BEN‐13580 Form_Revised 03/23/2009
529_0309