Opt-Out Affidavit Form
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1Opt-Out Affidavit
Provider Name ______________________________________________________________________
First)
(Middle)
(Last)
(Cred)
Provider Address ____________________________________________________________________
(Street)
(City)
(ST)
(Zip)
Social Security Number: ____________________ Date of Birth: __________ Specialty ________
Medical School: ____________________________________
Year Graduated: ___________
Medicare PTAN(s)_______________________
NPI Number _______________________
Telephone (___)_____________ Tax ID ___________________ License Number _______________
Contact Name:______________________ Phone #: _______________ Fax #________________
Contact Email ________________________________
• Except for emergency or urgent care services (as specified in Chapter 15 section 40 of the Medicare Benefit
Policy Manual), during the opt out period I will provide services to Medicare beneficiaries only through private
contracts that meet the criteria of §3044.8 for services that, but for their provision under a private contract, would
have been Medicare-covered services. The opt out period is 2 years and the contractor will notify me of the
effective date of this opt out period.
• I will not submit a claim to Medicare for any service furnished to a Medicare beneficiary during the opt-out
period, nor will I permit any entity acting on my behalf to submit a claim to Medicare for services furnished to a
Medicare beneficiary, except as specified in Chapter 15 section 40 of the Medicare Benefit Policy Manual.
• During the opt-out period, I understand that I may receive no direct or indirect Medicare payment for services
that I furnish to Medicare beneficiaries with whom I have privately contracted, whether as an individual, an
employee of an organization, a partner in a partnership, under a reassignment of benefits, or as payment for a
service furnished to a Medicare beneficiary under a Medicare+Choice plan.
• I acknowledge that during the opt-out period, my services are not covered under Medicare and that no Medicare
payment may be made to any entity for my services, directly or on a capitated basis.
• I acknowledge and agree to be bound by the terms of both the affidavit and the private contracts that I have
entered into during the opt-out period.
• I acknowledge and understand that the terms of the affidavit apply to all Medicare-covered items and services
furnished to Medicare beneficiaries by myself during the 2 year opt-out period (except for emergency or urgent
care services furnished to the beneficiaries with whom I have not previously privately contracted) without regard
to any payment arrangements I may make.
• I acknowledge that if I have signed a Part B participation agreement, that such agreement terminates on the
effective date of this affidavit. My affidavit should be submitted to the contractor within 30 days of the end of the
quarter.
• I acknowledge and understand that a beneficiary who has not entered into a private contract and who requires
emergency or urgent care services may not be asked to enter into a private contract with respect to receiving
such services and that the rules of Chapter 15 Section 40 of the Medicare Benefit Policy Manual apply if I furnish
such services.
• I have identified myself sufficiently so that the contractor can ensure that no payment is made to me during the 2
year opt-out period. If I have already enrolled in Medicare, I have included my Medicare PTAN and NPI, if one has
been assigned. If I have not enrolled in Medicare, I have included the information necessary to be assigned a
PTAN.
• I will file this affidavit with all contractors who have jurisdiction over claims that I would otherwise file with
Medicare and be filed no later than 10 days after the first private contract to which the affidavit applies is entered
into.
_________________________________________ _____________________
Provider Signature
Date
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