Consent For Care And Treatment Form Page 4

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:

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Parent category: Legal