Form Cms-460 - Medicare Participating Physician Or Supplier Agreement

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OMB No. 0938-0373
MEDICARE
PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT
Physician or Supplier
Name(s) and Address of Participant*
Identification Code(s)*
The above named person or organization, called "the participant," hereby enters into an agreement
with the Medicare program to accept assignment of the Medicare Part B payment for all services for
which the participant is eligible to accept assignment under the Medicare law and regulations and
which are furnished while this agreement is in effect.
1. Meaning of Assignment - For purposes of this agreement, accepting assignment of the
Medicare Part B payment means requesting direct Part B payment from the Medicare program.
Under an assignment, the approved charge, determined by the Medicare carrier, shall be the full
charge for the service covered under Part B. The participant shall not collect from the beneficiary or
other person or organization for covered services more than the applicable deductible and
coinsurance.
2. Effective Date - If the participant files the agreement with any Medicare carrier during the
enrollment period, the agreement becomes effective __________________.
3. Term and Termination of Agreement - This agreement shall continue in effect through
December 31 following the date the agreement becomes effective and shall be renewed
automatically for each 12-month period January 1 through December 31 thereafter unless one of the
following occurs:
a.
During the enrollment period provided near the end of any calendar year, the
participant notifies in writing every Medicare carrier with whom the participant has filed the
agreement or a copy of the agreement that the participant wishes to terminate the agreement at the
end of the current term. In the event such notification is mailed or delivered during the enrollment
period provided near the end of any calendar year, the agreement shall end on December 31 of that
year.
b.
The Centers for Medicare & Medicaid Services may find, after notice to and
opportunity for a hearing for the participant, that the participant has substantially failed to comply
with the agreement. In the event such a finding is made, the Centers for Medicare & Medicaid
Services will notify the participant in writing that the agreement will be terminated at a time
designated in the notice. Civil and criminal penalties may also be imposed for violation of the
agreement.
_________________________
________________________
____________
Signature of participant
Title
Date
(or authorized representative
(if signer is authorized
of participating organization)
representative of organization)
_________________________
(including area code)
Office phone number
*List all names and identification codes under which the participant files claims with the carrier with
whom this agreement is being filed.
Form CMS-460 (10/05) EF 02/2006

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