Affidavit To Opt Out Of Medicare Form printable pdf download

AFFIDAVIT TO OPT OUT OF MEDICARE

Participating physicians and practitioners must file an affidavit with the Medicare carrier no later

than 10 days after the first private contract is entered. The affidavit must be received by the

carrier at least 30 days before the first day of the next quarter showing an effective date of the

first day in that quarter (i.e. 1/1, 4/1, 7/1 and 10/1). This will be the termination date of the

Medicare participation agreement. Services should not be provided under private pay contracts

with beneficiaries earlier than the effective date of the affidavit. Non-participating physicians

and practitioners may opt out at any time. Any physician or practitioner should read the CMS

guidelines in

Chapter 15 Section 40

of the Medicare Benefit Policy Manual, prior to filing their

Opt out Affidavit.

Providers Full Legal Name ______________________________________________________________

Providers Business Address ______________________________________________________________

________________________________________________________________

Providers Mailing Address _______________________________________________________________

________________________________________________________________

Social Security Number _______________________________Date of Birth_______________________

Medicare PTAN(s)____________________________________NPI______________________________

Do you wish to be an Ordering/Referring provider? Yes__________________No__________________

Medical School_______________________ Year Graduated__________ Specialty _________________

Telephone _________________________ Tax ID_____________________ License #_______________

Contact Name_____________________________________ Telephone Number ___________________

Contact Email _______________________________________Fax Number_______________________

By signing this affidavit you acknowledge you understand and agree with the following

terms and conditions:

 I understand the Opt out period is for (2) two years beginning on the later of the date of

the affidavit is signed or its effective date.

 Except for emergency or urgent care services (as specified in §40.28), during the opt-out

period I will provide services to Medicare beneficiaries only through private contracts

that meet the criteria of §40.8 for services that, but for their provision under a private

contract, would have been Medicare-covered services;

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Affidavit To Opt Out Of Medicare Form