PRIVATE CONTRACT WITH A MEDICARE BENEFICIARY
This contract between ________________ and Dr. _________ (who first opted out
of Medicare on _______, and last restated this on ________ with expiration
on __________) will remain in effect during the opt out period. After that
time CMS may require the physician to sign and file an affidavit to renew
his opt out status. A new contract or a re-dating of this one may also have
to occur then. Dr. Schwartz has not been excluded from the Medicare program
under Sections 1128, 1156 and 1892 of the Social Security Act.
By signing this contract, the beneficiary or the beneficiary's legal
representative acknowledges, consents and/or agrees:
- To be fully responsible for payment of items or services.
- That they can choose a physician who has not opted out of Medicare and
that they have not been compelled to sign this contract.
- Not to submit a claim or to request the physician to submit a claim for
payment under Medicare.
- That Medigap plans do not, and that other supplemental insurance plans may
choose not to, make payment for items and services furnished by the
physician under the contract.
- That no reimbursement will be provided by Medicare for such items and
services (that would have otherwise been covered by a properly submitted
claim in the absence of a private contract).
- That the physician is not limited in the amount that he may charge the
beneficiary for items and services furnished.
- That this agreement was not signed when the beneficiary was facing an
emergency or urgent health care situation.
- That they are entitled to a copy of this contract, the original remains
with the medical record and CMS may demand a copy of it.
Witness:_________________ Patient/Representative:__________________
Physician:_______________ Date (for all signatures):______________
