Medicare Opt Out Form printable pdf download

Medicare Opt-Out Contract

Agreement Not to Bill Medicare for Services

The agreement is between Leslie C. Kilpatrick, M.Ed., LCSW whose principal place of business is 10400

Eaton Place Suite 200, Fairfax, VA and the client ________________________________ who resides at

___________________________________________________________________________ .

Ms. Leslie C. Kilpatrick is exclusively an out of network provider. For clients covered under Medicare,

the review and completion of this contact is also required by law.

In exchange for psychotherapy services, the client agrees to make payments directly to Ms. Leslie C.

Kilpatrick according to her fee schedule. The client also understands and expressly acknowledges the

following:

----------The client agrees not to submit a claim (or to request the clinician to submit a claim to

the Medicare program with respect to the services, even if covered by Medicare Part B)

----------The client is not currently in an emergency or urgent health care situation.

----------The client acknowledges that neither Medicare’s fee limitations nor any Medicare

reimbursement regulations apply to charges for the services.

----------The client acknowledges that Medigap plans will not provide payment or

reimbursement for services because payment is not made under the Medicare program, and

other supplemental insurance plans may likely deny reimbursement.

----------The client acknowledges that he/she has a right, as a Medicare beneficiary, to obtain

Medicare covered items from healthcare providers who have not opted out of Medicare.

----------The client agrees to be responsible to make payment in full for the services, and

acknowledges that the clinician will not submit a Medicare claim for the services and that no

Medicare reimbursement will be provided.

----------The client acknowledges that the Centers for Medicare and Medicaid have the right to

obtain a copy of this contract upon request

Medicare Opt Out Form