Medicare Contract printable pdf download

Medicare Contract

MEDICARE PRIVATE CONTRACT

IN COMPLIANCE WITH 42 U.S.c. §1395A; 42 C.F.R. §405, SUBPART D

This Private Contract (this "Contract") is entered into by and between the undersigned

physician (the "physician"), whose principal medical office is located at 218 E. Cheyenne

Mountain Blvd., Colorado Springs, CO

80906,

and the undersigned patient (the

"beneficiary").

Physician Obligations

The physician acknowledges that she is excluded from Medicare under sections

1128,

1156,

1892, or any other section of the Social Security Act.

The physician acknowledges that this contract shall not be entered into with the

beneficiary,

or the beneficiary's legal

representative,

during a time when the beneficiary

requires

emergency

care services or urgent care services, except that the physician may

furnish emergency or urgent care services to a Medicare beneficiary in accordance with

42 C.F.R.

§405.440.

The physician acknowledges that she must retain this contract (with original signatures)

for the duration of the opt-out

period,

and that it shall be made available to the Centers

for Medicare and Medicaid Services ("CMS") upon request.

The physician shall provide a copy of this Contract to the

beneficiary,

or to his or her

legal

representative,

before items or services have been furnished to the beneficiary under

the terms of this Contract.

The physician acknowledges that she must enter into a contract for each opt-out period.

Beneficiary Obligations

The beneficiary, or his or her legal

representative,

accepts full responsibility for

payment of the physician's charge for all services furnished by the physician.

The beneficiary, or his or her legal representative, understands that no payment will be

provided by Medicare for items or services furnished by the physician that would have

otherwise been covered by Medicare if there was no private contract and a proper

Medicare claim had been submitted.

The

beneficiary,

or his or her legal representative, understands that Medicare limits do

not apply to what the physician may charge for items or services furnished by the

physician.

The beneficiary, or his or her legal representative, agrees not to submit a

claim,

or ask the

physician to submit a claim, to Medicare for Medicare items or services, even if such

items or services are otherwise covered by Medicare.

The

beneficiary,

or his or her legal representative, has entered into this Contract with the

knowledge that he or she has the right to obtain Medicare-covered items and services

Medicare Contract

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