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.