Sample Affidavit For Opting Out Of Medicare (Page 5 of 6) in pdf

SAMPLE AFFIDAVIT FOR OPTING OUT OF MEDICARE

I, ________, declare under penalty of perjury that the following is true and correct to the best of my knowledge,

information, and belief:

1. I am a physician licensed to practice medicine in the state of ______. My address is at_________________ , my

telephone number is ______, and my [national provider number (NIP) or billing number, if one has been assigned,

uniform provider identification number (UPIN) if one has been assigned, or, if neither an NIP or UPIN has been

assigned, my tax identification number (TIN)] is ______. I promise that, for a period of two years beginning on the

date that this affidavit is signed (the "opt out" Period), I will be bound by the terms of both this affidavit and the

private contracts that I enter into pursuant to this affidavit.

2. I have entered or intend to enter into a private contract with a patient who is a beneficiary of Medicare pursuant to

Section 4507 of the Balanced Budget Act of 1997 for the provision of medical services covered by Medicare Part

B. Regardless of any payment arrangements I may make, this affidavit applies to all Medicare covered items and

services that I furnish to Medicare beneficiaries during the "opt out" period, except for emergency or urgent care

services furnished to beneficiaries with whom I had not previously privately contracted. I will not ask a Medicare

beneficiary who has not entered into a private contract and who requires emergency or urgent care services to

enter into a private contract with respect to receiving such services, and I will comply with 42 C.F.R. § 405.440 for

such services.

3. I hereby confirm that I will not submit, nor permit any entity acting on my behalf to submit, a claim to Medicare for

any Medicare Part B item or service provided to any Medicare beneficiary during the "opt out" period, except for

items or services provided in an emergency or urgent care situation for which I am required to submit a claim

under Medicare on behalf of a Medicare Beneficiary, and I will provide Medicare covered services to Medicare

beneficiaries only through private contracts that satisfy 42 C.F.R. § 405.415 for such services.

4. I hereby confirm that I will not receive any direct or indirect Medicare payment for Medicare Part B items or

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, during the "opt out" period, except for

items or services provided in an emergency or urgent care situation. I acknowledge that during the "opt out"

period, my services are not covered under Medicare Part B and that no Medicare Part B payment may be made

to any entity for my services, directly or on a capitated basis, except for items or services provided in an

emergency or urgent care situation.

5. A copy of this affidavit is being filed with [the name of each local Medicare carrier], the designated agent of the

Secretary of the Department of Health and Human Services, no later than 10 days after the first contract to which

this affidavit applies is entered into. [For participating physicians add: My Medicare Part B participation agreement

terminates on the effective date of this affidavit.]

Executed on [date] by [physician name]

[Physician signature]

Sample Affidavit For Opting Out Of Medicare Page 5