Medicare Opt Out Private Contract
Patient's Name
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First Name
Last Name
Patient's Date of Birth
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I, Elizabeth Landsverk MD / Michelle Dhanak MD (provider’s name), have not been excluded from
Medicare under [1128] §§1128, [1156] 1156 or [1892] 1892 of the Social Security Act.
I, the Medicare beneficiary or my legal representative, accept full responsibility for payment
of charges for all services furnished by Elizabeth Landsverk MD / Michelle Dhanak MD
(provider’s name).
I, the Medicare beneficiary or my legal representative, understand that Medicare limits do not apply to what Elizabeth Landsverk MD / Michelle Dhanak MD (provider’s name) may charge for items or services furnished.
I, the Medicare beneficiary or my legal representative, agree not to submit a claim to Medicare
or to ask Elizabeth Landsverk MD / Michelle Dhanak MD (provider’s name) to submit a claim
to Medicare.
I, the Medicare beneficiary or my legal representative, understand that Medicare payment will
not be made for any items or services furnished by Elizabeth Landsverk MD / Michelle Dhanak MD (provider’s name) that would have otherwise been covered by Medicare if there was no private
contract and a proper Medicare claim had been submitted.
I, the Medicare beneficiary or my legal representative, enter into this contract with the knowledge
that I have the right to obtain Medicare-covered items and services from a physician and/or practitioner who has not opted-out of Medicare, and that I am 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.
The expected or known effective date and expected or known expiration date of the opt-out
period is __________________ (effective date) and __________________ (expiration date).
I, the Medicare beneficiary or my legal representative, understand that Medigap plans do not,
and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
This contract cannot be entered into by myself, the Medicare beneficiary, or by my legal
representative during a time when I, the Medicare beneficiary, require emergency care
services or urgent care services. (However, a physician/practitioner may furnish emergency
or urgent care services to a Medicare beneficiary in accordance with §3044.28 of the Medicare
Carriers Manual)
I, the Medicare beneficiary or my legal representative, will receive or have received a copy (a photocopy is permissible) of this contract, before items or services are furnished to me under the terms of this contract.
I, Elizabeth Landsverk MD / Michelle Dhanak MD (provider’s name), will retain the original contract (original signatures of both parties required) for the duration of the opt-out period.
I, Elizabeth Landsverk MD / Michelle Dhanak MD (provider’s name), will supply CMS with a copy of this contract upon request.
I, Elizabeth Landsverk MD / Michelle Dhanak MD (provider’s name), understand that the current private contract remains in effect for two years. If I again opt-out of Medicare, I will expediently complete a new contract for each Medicare beneficiary and will expediently submit the appropriate affidavit(s) to all local Medicare carriers.
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Patient's Name
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First Name
Last Name
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Responsilble Party's Name
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First Name
Last Name
Responsible Party's Email
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example@example.com
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Responsible Party's Signature — Use your curser to sign in the box below
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Please Verify That You are Human
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Submit
v.9 - 2020 — Medicare Opt Out Private Contract
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