Psychology Signature Forms - Updated Medicare, upload 07-01-20

Patient's signature (or Representative)

Clear
Date

Month Day Year
Date
Patient's printed name
Patient's date of birth

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

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

Month Day Year
Date
Signature of Claimant/Patient or Parent or Legal Guardian of Claimant/Patient

Clear
Patient Signature

Clear
Date

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

Clear
Date

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

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

Clear
Date

Month Day Year
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
This agreement is entered into by me and Psychologist, Shelley Tindell-Nodine Psy.D. If I choose to receive 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 have been furnished to me under the terms of this contract. I or my legal representatives understand that I 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 07/01/2020-06/30/2022 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:

Month Day Year
Date
Signature of Beneficiary - Patient or Parent/Guardian/Auth Rep.

Clear
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)

Clear
Date

Month Day Year
Date
(Relationship to patient if not signed by patient)
Signature of patient or guardian

Clear
Date

Month Day Year
Date
Patient's printed name
Patient's date of birth

Month Day Year
Date
Patient's social security number (LAST FOUR DIGITS ONLY)
Should be Empty:

Neurology and Physical Therapy Centers of Tampa Bay