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Medicare Opt Out form

  • Medicare Opt Out Contract

    Private 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

  • 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:

    Check to agree

  • MM slash DD slash YYYY
  • By:
    Beneficiary or his/her legal representative, and
    Nancy K. Lonsdorf, M.D., P.C.

Nancy K. Lonsdorf, MD
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