The Patient and/or the Patient's legal representative:

• Accepts full responsibility for payment of Practitioner's charge(s) for all services furnished by the Practitioner.
• Understands that Medicare/Medicaid limits do not apply to what the Practitioner may charge for items or services furnished by the Practitioner.
• Agrees not to submit a claim to Medicare or Medicaid or to ask the Practitioner to submit a claim.
• Understands that Medicare or Medicaid insurance payment will not be made for any items or services furnished by the Practitioner that would have otherwise been covered by insurance if there was no private contract and a proper claim had been submitted.
• Enters into this contract with the knowledge that he/she has the right to obtain Medicare, Medicaid or other out-of-network insurance covered items and services from Practitioners who do accept Medicare, Medicaid and are in-network providers.
• Is not compelled to enter into this private contract that could be furnished by other Practitioners who accept Medicare, Medicaid and are in-network.
• Understands 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.
• Has not entered this private contract during a time when the Patient requires emergency care services or urgent care services.
• Acknowledges his/her understanding that the Practitioner has not been excluded from participation under the Medicare program under section 1128, 1156 or 1892 of the Social Security Act.
• Has signed this private contract prior to any services provided under the private contract's terms.
• Understands that either party may choose to terminate treatment with reasonable notice to the other party.
• Understands that the obligation not to pursue Medicare/Medicaid reimbursement for such items or services provided under this private contract shall survive this private contract.
• Agrees that this private contract shall be fully binding on the Parties' heirs and successors.
• Understands that a copy of this private contract will be provided at the request of the Patient and/or to his/her legal representative before items or services are furnished to the Patient under the terms of the private contract.
• Understands that this private contract will be retained (original signatures of both parties required) by the Practitioner for the duration of the private contract.
• Agrees that the Practitioner can supply CMS/Medicare/Medicaid with a copy of this private contract upon request.

I (“Patient”) have elected to receive ‘direct pay’ services provided by (“Practitioner”). I (“Patient”) understand that to receive these ‘direct pay’ services I am required to pay the fees for services at the time services are rendered.