Noridian Medicare Private Contract Page 2
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2I _____________________________(provider’s name) will retain the original contract (original signatures of
both parties required) for the duration of the opt-out period.
I _____________________________(provider’s name) will supply CMS with a copy of this contract
upon request.
I _____________________________(provider’s name) understand that the current private contract
remains in effect for two years. If I again opt-out of Medicare, I will expediently complete a new contract
for each Medicare beneficiary and will expediently submit the appropriate affidavit(s) to all local
Medicare carriers.
Provider’s NPI: ________________
Provider’s Signature: _______________________________________________________ Date: _________________
Patient’s Signature: ________________________________________________________ Date: _________________
Patient’s Legal Representative Signature: ____________________________________ Date: _________________
Witness: __________________________________________________________________ Date: _________________
Contact Name:____________________________________________ Phone #: _______________________________
Contact Email: ____________________________________________________________________________________
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Parent category: Medical