Private Contract With Medicare Beneficiaries (Opting Out printable pdf download

Private Contract With Medicare Beneficiaries (Opting Out

Private Contract with Medicare Beneficiaries (Opting Out)

Dear Medicare beneficiaries:

Please be aware that this office (Lan Su, DMD, PhD, the provider) has opted out

Medicare. We will not file claims for Medicare or any other organization which receives

reimbursement from Medicare.

By signing this contract, you agree or acknowledge the following provisions:

Agree not to submit a claim to Medicare;

Agree to pay the provider for the service;

Agree to pay “full-fee” for the service;

Acknowledge that supplemental insurance may not make payment because

Medicare will not make payment;

Acknowledge that you (the beneficiary) can choose to go to another

physician and have Medicare reimburse for the services.

I have read the above provisions. I understand these provisions and agree to this

contract.

X_______________________________

Date______________

Signature of responsible party/patient

X_______________________________

Date_______________

Witnessed by

Private Contract With Medicare Beneficiaries (Opting Out