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

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?

No Yes
*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:

Month Day Year
Date
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?

Yes No
Signature

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Name

First Name Last Name
Letter of Protection and Authorization
I authorize Vincent DiCarlo, M.D. & Associates, P.A. d/b/a Neurology and Physical Therapy Centers of Tampa Bay (“Provider”) to furnish to my attorney(s), their employees and agents who represent/represented me regarding any claim(s) related to my accident/loss with a full report of examination, diagnosis, treatment, prognosis and any medical information or any information regarding services provided to me, including all records received for care from other sources, billing information and any other information regarding me which may be in Provider’s possession. I authorize, direct and hereby notify my attorney(s) who represent(s)/represented me regarding any claim(s) related to my accident/loss to pay directly to Provider all sums that are due for all services Provider rendered to me regarding my accident/loss and to withhold such sums from any settlement, judgment or verdict. I agree to keep Provider updated if there is a change in status with my current attorney(s) and if there are any changes to my representation. If there is a change, I agree that this letter of protection and authorization will also apply to my new attorney(s). I understand that I am directly responsible to the Provider for all bills for Provider’s services rendered to me, regardless of payment source. I understand payment is not contingent on any settlement, judgment or verdict by which I may eventually recover payment for Provider’s services.
Patient Name
Date of accident/loss:

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Signature of Patient/Claimant or Parent or Legal Guardian

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Should be Empty:

Neurology and Physical Therapy Centers of Tampa Bay

NOTICE TO ALL PATIENTS:

Letter of Protection and Authorization