Medicare Opt Out Contract
Medical Opt Out Contract
This agreement is a required document by the Federal Government, between Nancy K. Lonsdorf, MD, PC whose principal place of business is 1100 N. 4th St, Suite 105, Fairfield, IA 52556 and
Who resides at:
Medicare ID #:
and 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 Beneficiary or his/her legal representative that Physician has opted out of the Medicare program effective on May 6, 2018 for a period of at least two years, to expire on May 6, 2020 and automatically renew every two years. The physician is not excluded from participating in Medicare Part B under Section 1128, 1156, or 1892 of the Social Security Act.
Beneficiary or his/her legal representative agrees, understands and expressly acknowledges the following:
Nancy K. Lonsdorf, M.D., P.C.
Leave this empty:
Your legal name
If you have questions about the contents of this document, you can email the document owner.
Document Name: Medicare Opt Out Contract
Agree & Sign