Psychology Signature Forms - Updated Medicare, upload 07-01-22

Patient's signature (or Representative)

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Patient's printed name
Patient's date of birth

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Patient's social security number (LAST FOUR DIGITS ONLY)
Patient Name:
Date of loss/accident:

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By signing below the parties agree to the above on the Effective Date:

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Signature of Claimant/Patient or Parent or Legal Guardian of Claimant/Patient

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Patient Signature

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Print Patient Name
If patient is a minor (under age 18): Signature of Individual Authorized to Sign for Minor Patient

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Relationship to Minor Patient:
Do you have Medicare, are you a Medicare beneficiary or are you enrolled in Medicare in any form?

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*IF NO, SIGN HERE ONLY: Signature of patient or Parent/Guardian/Auth Rep.

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Printed Name
[Signed on behalf of ___________ (name of patient) if signed by parent/guardian/authorized representative]
Neurology and Physical Therapy Centers of Tampa Bay

Vincent Di Carlo, M.D. & Associates, P.A. 2835 W. De Leon Street, Suite 205 Tampa, FL 33609(813) 831-6622
ThisagreementisenteredintobymeandPsychologist,ShelleyTindell-NodinePsy.D.IfI choosetoreceive services provided by Psychologist, I or my legal representatives understand that Psychologist has opted

out of Medicare. Therefore, I or my legal representatives understand, acknowledge and agree to the following:

I or my legal representatives have the right to cancel my appointment at this facility and obtain Medicare-covered items and services from a Psychologist at another facility who has not opted out of Medicare and for whom payment would be made by Medicare for their covered services. I or my legal representatives have not been compelled to enter into private contracts that apply to other Medicare covered services furnished by other practitioners or physicians who have not opted out.

Psychologist has provided a copy of this contract to me or my legal representatives before items or services havebeenfurnishedtomeunderthetermsofthiscontract. IormylegalrepresentativesunderstandthatI accept full responsibility for payment of all services furnished by Psychologist. No payment will be provided by Medicare to me or my legal representatives for items or services furnished by Psychologist that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.

Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. Regarding emergency care services or urgent care services as specified in 42 C.F.R. Sec. 405.440, this contract does not apply nor can I be required to enter into it. Psychologist is not excluded from Medicare under Sec. 1128, Sec. 1156 or Sec. 1892 or any other section of the Social Security Act.

Medicare limits do not apply to what the Psychologist may charge for items or services furnished by Psychologist. I agree not to submit a claim, nor ask Psychologist to submit a claim to Medicare for

Medicare items or services, even if such items or services are otherwise covered by Medicare.
The Opt Out Period is 07/01/2022-06/30/2024 and is automatically renewed for subsequent two year periods

thereafter unless otherwise notified in writing.
This agreement is effective on the date indicated below.
Effective Date:

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Signature of Beneficiary - Patient or Parent/Guardian/Auth Rep.

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Printed Name
[Signed on behalf of _________ (name of patient) if signed by parent/guardian/authorized representative]
Print Name
Signature of patient (or patient guardian or representative)

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(Relationship to patient if not signed by patient)
Signature of patient or guardian

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Patient's printed name
Patient's date of birth

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Patient's social security number (LAST FOUR DIGITS ONLY)
NOTICE TO ALL PATIENTS:

THE PROVIDERS AT OUR CLINIC ARE NOT MEDICAID PROVIDERSIF YOU HAVE MEDICAID, PLEASE INFORM OUR STAFF IMMEDIATELY _____Yes, I am a Medicaid recipient ____No, I am not a Medicaid recipient Due to notification from the Florida Agency for Healthcare Administration regarding federal regulations as of October 1, 2021, with regard to patients who are Medicaid recipients, our providers will no longer prescribe medication that is billed to Medicaid or provide referrals for services that are billed to Medicaid. THEREFORE, ANY RECOMMENDATIONS RECEIVED AT OUR CLINIC FOR TREATMENT BILLED TO MEDICAID MUST BE FOLLOWED THROUGH WITH YOUR MEDICAID PRIMARY CARE PHYSICIAN OR A HEALTHCARE PROVIDER ENROLLED IN MEDICAID I understand the above and agree that if I am a Medicaid recipient or if I become a Medicaid recipient in the future that I will immediately inform the clinic providers and understand that the providers at this clinic cannot prescribe any medication to me that is billed to Medicaid and that any recommendations for treatment that are billed to Medicaid must be followed through with my Medicaid primary care physician or another healthcare provider enrolled in Medicaid. ____________________________ Signature ___________________Date_____________________________ (print name)
Are you a Medicaid receipient?

YesNo
Signature

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Patient Name
Should be Empty:

Neurology and Physical Therapy Centers of Tampa Bay

NOTICE TO ALL PATIENTS: