This agreement is made by and between Maryal Concepcion, M.D. ("Physician"), Jeremiah Fillo, M.D. ("Physician") and Big Trees MD ("Practice") on the one hand, and the individual listed above on the other hand ("Patient" or "Beneficiary" Patient is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. Practice has informed Beneficiary or his/her legal representative that Physicians of Practice have opted out of the Medicare program. Physicians of Practice have not been excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 of the Social Security Act. Beneficiary or his/her legal representative agrees, understands, and expressly acknowledges the following:
Please read each line carefully and initial to indicate your agreement with the statement. I want the services provided by Physician and Practice. I understand that Medicare will not be billed for these services and I will be paying out of pocket for these services. I accept full responsibility for payment of the Physician's charges for all services furnished by the Physician. I understand that Medicare limits do not apply to what the Physician may charge for items or services furnished by the Physician. I agree not to submit a claim to Medicare or to ask the Physician to submit a claim to Medicare.
Iunderstand that Medicare payment will not be made for any items or services furnished by the Physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
I am entering into this contract with the knowledge that I have the right to obtain Medicare-covered items and services from Physicians and practitioners who have not opted out of Medicare, and I am not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other Physicians or practitioners who have not opted out. Iunderstand that the Physician has elected for a rolling opt-out period and that there is no expected expiration date of the opt-out period. I understand that Medi-Gap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. I acknowledge that I am not currently in an emergency or urgent health care