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
Beneficiary or his/her legal representative, and
Nancy K. Lonsdorf, M.D., P.C.