Printable PDF Medicare Private Contract
Damian Garcia, M.D.
3450 West Wheatland Road, Suite 235
Dallas, Texas 75237 972-224-1122
MEDICARE OPT-OUT PRIVATE PATIENT CONTRACT
This agreement is between Dr. Damian Garcia (“Physician”) and patient _____________________________________ (“Patient”), date of birth __________________________ who 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 01/01/2017 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 usual in-office medical services to Patient (the “Services”). In exchange for the Services, the Patient agrees to make payments to Physician pursuant to his Self-Pay Fee Schedule. Patient also agrees, understands and expressly acknowledges the following:
* Patient agrees not to submit a claim (or to request that Physician submit a claim) to the Medicare program with respect to 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 Medi-Gap and Medicare Advantage 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 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. (If Patient has Medicare Part D coverage, prescriptions issued by Physician will still be covered if they would be covered when prescribed by a Medicare Participating Provider.)
* Patient acknowledges that a copy of this contract has been made available.
* Patient agrees to reimburse Physician for any costs and reasonable attorneys’ fees that result from violation of this Agreement by Patient or his beneficiaries.
Executed by [Patient name] ______________________________ and Damian Garcia, M.D. on [date] ______________________
[Patient signature] __________________________________________________________________ [Physician signature]_____