Fillable Medicare Private Contract - Ciampi Family Practice (Page 2 of 2) in pdf

3. Physician acknowledges that (s)he will not execute this contract at a time when the patient is facing an

emergency or urgent health care situation.

B. Obligations of Patient

1. Patient or his/her legal authorized representative agrees not to submit a claim (or to request that the physician

submit a claim) under the Medicare program for such items or services as physician may provide, even if

such items or services are otherwise covered under the Medicare program.

2. Patient or his/her legal authorized representative agrees to be responsible, whether through insurance or

otherwise, for payment of such items or services and understands that no reimbursement will be provided

under the Medicare program for such items or services.

3. Patient or his/her legal authorized representative acknowledges that that Medicare limits do not apply to

what the physician/practitioner may charge for items or services furnished by the physician/practitioner.

4. Patient acknowledges that Medigap plans do not, and other supplemental insurance plans may elect not to,

make payments for items and services not paid for by Medicare.

5. Patient acknowledges that (s)he has the right to obtain Medicare‐covered items and services from physicians

and practitioners who have not opted out of Medicare, and that the (s)he is not compelled to enter into

private contracts that apply to other Medicare covered services furnished by other physicians or practitioners

who have not opted out.

6. Patient acknowledges that (s)he or his/her legal representative understands that Medicare payment will not

be made for any items or services furnished by the physician/practitioner that would have otherwise been

covered by Medicare if there were no private contract and a proper Medicare claim had been submitted.

C. Physician’s Status

Patient further acknowledges his/her understanding that physician (has/ has not) been excluded from

participation under the Medicare program under Section 1128.

D. Term and Termination

This agreement shall commence on the above date and shall continue in effect until ________________ (physician

should insert date which is two [2] years after [s]he signs the affidavit). Despite the term of the agreement, either

party may choose to terminate treatment with reasonable notice to the other party. Notwithstanding this right to

terminate treatment, both physician and patient agree that the obligation not to pursue Medicare reimbursement,

for items and services provided under this contract, shall survive this contract.

I have read and understand the provisions regarding private contracting.

By signing this contract, I accept full responsibility for payment of the physician’s or practitioner’s charges for all

services furnished to me from the date written above.

Michael A. Ciampi, M.D.

_________________________________________________

_____________________________________________

Name of Physician (printed)

Name of Patient (printed)

_________________________________________________

_____________________________________________

Signature of Physician

Signature of Patient

_________________________________________________

_____________________________________________

Date

Medicare Private Contract - Ciampi Family Practice Page 2