EXPLANATION OF MEDICARE
CHARGES AND PAYMENTS
I understand that Medicare will cover approved charges at 80% of
the allowable costs and that either my secondary coverage or I will
be responsible for the remaining 20%.
If the calendar year deductible has not been met when Dr. Bozof’s
charges are processed through the Medicare system I will also be
responsible for the amount credited towards the deductible.
I further understand and acknowledge that Medicare will process
and pay claims based upon the current fee schedule and that Dr.
Bozof will not bill me for charges in excess of the approved
amount. I will, however be billed any co-insurance that is not paid
by a secondary carrier.
Patient Signature
Printed Name:
Date
Witness: