Please initial in the space provided that you or your representative completely understand the following statements. Please feel free to discuss these at length before beginning treatment. You may speak with your doctor or the office administrative staff, if you have any questions.
- It is important to note that Dr. Nicholls, Dr. Hoffman, Dr. Logerquist, Dr. Lebovitz, Dr. Sanchez, and Dr. Matteson have never been excluded from participating in Medicare under statues [1128] §§1128, [1156] 1156 or [1892] 1892 of the Social Security Act. They have chosen not to continue as a Medicare provider due to responses to properly filed billing forms taking as long as six months from date of service. There are often denials for unexplained reasons. Additionally, ongoing cuts in reimbursement and the excessive secretarial time necessary to collect these fees have led to our decision to opt out of this insurance plan. Patient or patient representatives initials here: