Medicare Beneficiary Private Contract printable pdf download

Medicare Beneficiary Private Contract

MEDICARE BENEFICIARY PRIVATE CONTRACT

This Medicare Beneficiary Private Contract (“Agreement”) is by and between Simone L.

Norris , M.D., 18720 Stone Oak Parkway, Suite 201, San Antonio, Texas, 78258 (“Physician”)

and the following Patient, who is a Medicare beneficiary:

Name: _____________________________________________________

Address: ___________________________________________________

___________________________________________________

SSN: ____________________________________________________

Date of Birth: ________________________________________________

NOTE: If the above Patient has a legal representative who is responsible for signing this

Agreement, the Legal Representative is identified as follows:

Name:_______________________________________________________

Address:______________________________________________________

______________________________________________________

Relationship to Patient:__________________________________________

For purposes of this Agreement, the term "Patient" as used hereafter shall include the

Patient or his or her legal representative.

1. Purpose of Agreement. The purpose of this Agreement is to set forth the agreement

between Physician and Patient for payment as a consequence of Physician's election to "opt

out" of the Medicare reimbursement system for Medicare Part B Physicians and

Practitioners, under §1802 of the Social Security Act, as amended by §4507 of the Balanced

Budget Act of 1997.

2. Physician Status as Medicare Part B Physician.

a. Physician hereby informs Patient that Physician has elected to "opt out" of the

Medicare Part B Reimbursement program by filing the required forms with the Medicare

Carrier, for a period of at least two years.

b. Physician has NOT been otherwise excluded from participation in the Medicare

program under § 1128, § 1156, or§ 1892 of the Social Security Act.

c. Physician may NOT submit bills to a Medicare carrier for payment for the

treatment of a Medicare Part B beneficiary during the "opt out" period.

d. Patient may NOT submit bills from Physician for treatment of Patient to a

Medicare Carrier during the "opt out" period, even though such treatment would be

otherwise covered by Medicare.

Medicare Beneficiary Private Contract