Medicare Opt-Out Form - Family To Family printable pdf download

MEDICARE OPT OUT AGREEMENT

PRIVATE CONTRACT AND RELATIONSHIP WITH FAMILY TO FAMILY

Including Dr. Lichtig, Dr. Bradt , and Dr. Hanaway

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By signing this document, I, __________________________________ {print name

, agree that Family

to Family has notified me of the following information, and I agree to the terms of this relationship with

them.

1. Family to Family’s health care providers, Drs. Lichtig and Bradt, have chosen to not be Medicare

Providers. As a result, they are agreeing to be excluded from participating in the program under

1128 of the Social Security Act.

2. By signing this contract, I agree to not request that a claim be submitted on my behalf by Family

to Family, and I agree to not submit a claim on my own behalf for services rendered by the

physicians at Family to Family for payment under Medicare, even if such items and services

would otherwise be covered by Medicare.

3. I am aware that Medigap plans do not make payment for items and services that Family to Family

has furnished and that other supplemental insurance plans may also decline to make payments.

4. I agree to and am responsible for payment of services rendered at Family to Family, and

Medicare will not provide reimbursement for such items or services.

5. I understand that Family to Family does not have to follow the limiting fee schedule enforced by

Medicare and can determine their own fees and charges independently.

6. I understand that I have the right to have such items and services provided to me by other

physicians and practitioners who have not “opted out” of the Medicare program.

7. I understand that there are a number of non-covered services that Medicare has not and does not

cover such as routine physical exams.

8. I understand that the doctors at Family to Family can still order labs and diagnostic tests from

facilities who are participating providers with Medicare and that those facilities can submit claims

to Medicare on my behalf.

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Signature of Patient

Date

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Signature of Witness

Date

Medicare Opt-Out Form - Family To Family