Fillable Medicare Opt Out Private Contract - Noridian printable pdf download

Medicare Private Contract

Section 4507 of the 1997 Balanced Budget Act allows a physician or practitioner to enter a private

contract with a Medicare beneﬁciary. Enter the provider’s name and the beneﬁciary’s name in the

appropriate boxes. Signatures from the provider, a witness and the patient/beneﬁciary or their legal

representative are required below. The supplier must submit an afﬁdavit to Medicare expressing his/her

decision to opt-out.

I _____________________________(provider’s name) have not been excluded from Medicare under

sections 1128, 1156 or 1892 of the Social Security Act ________________(provider’s NPI)

I (the Medicare beneﬁciary) or my legal representative accept full responsibility for payment of charges

for all services furnished by _____________________________(provider’s name).

I (the Medicare beneﬁciary) or my legal representative understand that Medicare limits do not apply to

what _____________________________(provider’s name) may charge for items or services furnished.

I (the Medicare beneﬁciary) or my legal representative agree not to submit a claim to Medicare or to ask

_____________________________(provider’s name) to submit a claim to Medicare.

I (the Medicare beneﬁciary) or my legal representative understand that Medicare payment will not

be made for any items or services furnished by _____________________________(provider’s name)

that would have otherwise been covered by Medicare if there was no private contract and a proper

Medicare claim had been submitted.

I (the Medicare beneﬁciary) or my legal representative enter into this contract with the knowledge that

I have the right to obtain Medicare-covered items and services from a physician and/or practitioner

who has not opted-out of Medicare, and I am 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.

The expected or known effective date and expected or known expiration date of the opt-out period is

_______________(effective date) and _______________(expiration date).

I (the Medicare beneﬁciary) or my legal representative understand that Medigap plans do not,

and that other supplemental plans may elect not to, make payments for items and services not paid

for by Medicare.

This contract cannot be entered into by me, (the Medicare beneﬁciary), or by my legal representative

during a time when I, (the Medicare beneﬁciary), require emergency care services or urgent care

services. (However, a physician/practitioner may furnish emergency or urgent care services to a

Medicare beneﬁciary in accordance with 3044.28 of the Medicare Carriers Manual)

I (the Medicare beneﬁciary) or my legal representative will receive or have received a copy

(a photocopy is permissible) of this contract, before items or services are furnished to me under the

terms of this contract.

29375069

(04611) 3-16

Medicare Opt Out Private Contract - Noridian