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

SAMPLE CONTRACT WITH BENEFICIARY

This agreement is between Dr._______, whose principal place of business is _______, and patient __________, who

resides at _____________and is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant

to Section 4507 of the Balanced Budget Act of 1997. The physician has informed patient that physician has opted out of

the Medicare program effective on __________ for a period of at least two years, and is not excluded from participating in

Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.

Physician agrees to provide the following medical services to the patient:

[List Services Here]

In exchange for the services, the patient agrees to make payments to physician pursuant to the attached fee schedule.

Patient also agrees, understands and expressly acknowledges the following:

(Patient please initial each line)

_____Patient agrees not to submit a claim (or to request the physician submit a claim) to the Medicare program with

respect to the services, even if covered by Medicare Part B.

_____Patient is not currently in an emergency or urgent health care situation.

_____Patient acknowledges that neither Medicare's fee limitations nor any other Medicare reimbursement regulations

apply to charges for the services.

_____Patient acknowledges that Medigap plans will not provide payment or reimbursement for the services because

payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny

reimbursement.

_____Patient acknowledges that he/she has a right, as a Medicare beneficiary, to obtain Medicare covered items and

services from physicians and practitioners who have not opted out of Medicare, and that the patient is not compelled to

enter into private contracts that apply to other Medicare covered services furnished by other physicians or practitioners

who have not opted out.

_____Patient agrees to be responsible, whether through insurance or otherwise, to make payment in full for the services,

and acknowledges that physician will not submit a Medicare claim for the services and that no Medicare reimbursement

will be provided.

_____Patient understands that Medicare payment will not be made for any items or services furnished by the physician

that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were

submitted.

_____ Patient acknowledges that a copy of this contract has been made available to him/her.

_____Patient agrees to reimburse physician for any costs and reasonable attorney fees that result from violation of this

agreement by the patient or his/her beneficiaries.

Executed on by (patient name) and (physician name).

(PATIENT SIGNATURE)

(PHYSICIAN SIGNATURE)

Sample Affidavit For Opting Out Of Medicare Page 6