Medicare Opt Out form :: Nancy K. Lonsdorf, MD

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
Beneficiary*
First Last
Who resides at*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
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:

Check to agree
1*
- Beneficiary or his/her legal representative accepts full responsibility for payment of the physician’s charge for all services furnished by the physician.
2*
- Beneficiary or his/her legal representative understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician.
3*
- Beneficiary or his/her legal representative agrees not to submit a claim to Medicare or to ask the physician to submit a claim to Medicare.
4*
- Beneficiary or his/her legal representative understands that Medicare payment will not be made for any items or services furnished by the physician that would otherwise be covered by Medicare if there was not a private contract and a proper Medicare claim had been submitted.
5*
- Beneficiary or his/her legal representative enters into this contract with the knowledge that he/she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and the beneficiary is not compelled to enter into private contracts that apply to other Medi9/19/19care-covered services furnished by other physicians or practitioners who have not opted out of Medicare.
6*
- Beneficiary or his/her legal representative understands that Medi-Gap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
7*
- Beneficiary or his/her legal representative acknowledges that the beneficiary is not currently in an emergency or urgent health care situation.
8*
- Beneficiary or his/her legal representative acknowledges that a copy of this contract has been made available to him.
Executed on*
Date Format: MM slash DD slash YYYY
By:
Beneficiary or his/her legal representative, and
Nancy K. Lonsdorf, M.D., P.C.

Medicare Opt Out form

Medicare Opt Out Contract