Medicare Private Pay Contract printable pdf download

MARCIA JOHNSTON WOOD, Ph.D.

Clinical Psychologist

_____________

5441 SW Macadam, #104, Portland, OR 97239

Phone (503) 248-4511/ Fax (503) 248-6385

Medicare Private Pay Contract

Dear Client,

I am writing this letter to notify you that as of July 1, 2015, I chose to continue opting-out of Medicare for

a two-year period as permitted by the Balance Budget Act of 1997 (Section 1802(b) of the Social Security

Act). This law allows psychologists who have opted out of Medicare to enter into a private contract with

Medicare beneficiaries for that specific two-year opt-out period and requires that a private contract be

signed by you and by me for each opt-out period.

When signed by you or your legal representative below, under the heading “Agreed and Accepted”, this

letter will become a private contract.

Upon entering into such a private contract with you, I may provide medical care to you and bill you at my

usual rates for medical care that is ordinarily covered by Medicare. Please note that I will not be

submitting any claims to Medicare for these services. I am asking you (as required by law) to sign this

private contract that covers the period 7/1/2015 - 6/30/2017.

The opt-out law has strict requirements, including my informing you that I am not excluded from the

Medicare program (under Section 1128 of the Social Security Act). The law also requires that you or

your legal representative sign the private contract in advance of the first service furnished under this

private contract. In addition, the law provides that, at the time of signing the private contract, you must

not be facing an emergency or urgent healthcare situation, in which case I could help refer you to other

covered entities.

In addition to the requirements given above, the law also mandates that a private contract must include the

provisions listed below. Please read this entire letter carefully and ask me any questions you may have

before you sign it to ensure that you understand, agree and expressly acknowledge all of its terms.

By signing this letter, you agree that you shall not submit a claim or ask me to submit a claim for payment

under Medicare for my services, even if such items and services would otherwise be covered by Medicare.

This means that you agree not to bill Medicare or ask me to bill Medicare. This also means that you will

give up Medicare coverage of, and payment for, items and services furnished by me because I have opted

out of Medicare.

By signing this letter, you also acknowledge that Medigap insurance plans do not, and that other

supplemental insurance plans may choose not to, make payments for items and services furnished by me

while this contract is in effect because payment for my services will not be made by Medicare.

You agree to be fully responsible, through private insurance or otherwise, for payment of items or

services provided by me. You acknowledge that no reimbursement will be provided by Medicare to you

or to me for items and services provided by me. You acknowledge that I am not limited in the amount

that I may charge you for the items and services that I provide to you. However, the amount of these fees

will be provided in advance. This means that any fee limit or Medicare reimbursement regulations that

Medicare Private Pay Contract